Manager, Inpatient and Post Acute Services

This is a fully remote position, open to applicants in Florida.

📋 Description

• Manage daily operations related to utilization management for inpatient services, including clinical assessment, authorization, and ongoing reviews.

• Ensure prompt level-of-care decisions are in accordance with clinical guidelines and regulatory standards.

• Collaborate with hospital case managers, healthcare providers, and interdisciplinary teams to create safe and cost-effective discharge plans.

• Track inpatient length of stay, readmissions, key performance indicators (KPIs), and turnaround times to pinpoint areas for improvement.

• Supervise utilization review for skilled nursing facilities, home health services, long-term acute care, and other post-acute care settings.

• Establish care transitions with post-acute providers to minimize avoidable readmissions.

• Utilize evidence-based protocols to assess medical necessity and manage cost-effectiveness in post-acute care.

• Lead Dual Special Needs Plan (DSNP) utilization management while incorporating Medicare and Medicaid requirements.

• Address the specific needs of DSNP enrollees, including social determinants of health.

• Ensure adherence to state and federal regulations, contractual obligations, authorizations, and appeals processes.

• Develop and revise utilization management policies and procedures as needed.

• Prepare for and oversee internal and external audits.

• Assist the Utilization Management Director with new initiatives and departmental projects.

• Directly oversee staff involved in inpatient, post-acute, and DSNP utilization management.

• Recruit, train, mentor, assess, and develop team members effectively.

• Create and monitor the department's annual budget.

• Drive process improvement through Lean methodologies, visual management tools, and daily huddles.

• Participate in managerial meetings and strategic internal and external committees.

• Develop performance metrics and deliver monthly/quarterly dashboards and actionable reports to senior leadership.

• Serve as the backup for the Director of Utilization Management on an as-needed basis.

• Adhere to privacy policies and HIPAA regulations while performing other assigned responsibilities.

⛳️ Requirements

• At least seven (7) years of clinical experience.

• A minimum of 3 years of experience in direct health plan roles focusing on case management, utilization management, or disease management.

• Previous supervisory or management experience is required.

• Registered Nurse or Licensed Clinical Social Worker with valid state licenses.

• Preferred: Certified Case Manager Certification accredited by CCMC.

• Comprehensive understanding of medical procedures, diagnoses, care modalities, procedure codes, ICD-9 and ICD-10, and CPT codes.

• Familiarity with health insurance and mandated benefits in the State of Oregon.

• Knowledge of managed care products and third-party liability (TPL).

• Capability to develop, review, and analyze utilization and case management reports.

• Prior experience in adult education is preferred.

• Proficient in reading and understanding written and spoken English.

• Strong and effective communication skills.

• Ability to stoop and bend as necessary.

• Capacity to sit and/or stand for prolonged periods.

• Competence in performing repetitive typing, sorting, and filing tasks.

• Ability to lift and carry files and business materials.

• Approximately 10% travel may be required.

🏝️ Benefits

• Opportunities for continuing education events.

• Professional development programs available.

• Equal opportunity employment practices.

• Work environment that promotes diversity, equity, inclusion, and social justice.

• Ergonomically designed equipment.

• At-will employment policy.