Senior Manager of Utilization Management & Case Management

Overview

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 54 hospitals and has more than 360 outpatient locations in 15 states providing more than 3.0million patient visits annually. It is one of the nation’s leading health systems with over 60,000 employees and physicians. Twenty-one of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team!

Responsibilities

The Senior Manager of Utilization Management & Case Management provides strategic leadership and operational oversight for core clinical operations, including outpatient prior authorization, inpatient concurrent review, case management, and medical appeals. This role ensures the delivery of high-quality, cost-effective care that aligns with regulatory standards (NCQA, CMS, state mandates) and health plan policies while leading a high-performing team of clinical and non-clinical professionals

Qualifications

Required qualifications:

 

1. Active, unrestricted Licensed Vocational Nurse (LVN) license in the state of operation (highly preferred). Lean or advanced clinical degrees (e.g., RN, BSN, MSN, LCSW) are a plus.

 

2. Certified Case Manager (CCM) or Certified Professional in Utilization Review (CPUR) designation is highly desirable or relevant experience managing teams.

 

3. 5+ years of clinical nursing or healthcare experience.

 

4. 3-5 years of progressive leadership/management experience within a managed care organization (MCO), health plan, or insurance setting.

 

5. Deep knowledge of Medicare, Medicaid, Commercial, and Marketplace insurance regulations.

 

6. Proficiency with health plan software (e.g., MCG, InterQual, CMS).

 

7. Strong data analytics skills to translate operational metrics into actionable clinical strategies.

Pay Transparency

Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options.  Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary.  A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $110,968.00 to $173,035.20 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

Employment Status

Full Time

Shift

Days

Equal Employment Opportunity

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf

Privacy Notice

Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf