System Director, Operational Utilization Review

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.

Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.

Job Summary:

Provides comprehensive oversight of the utilization review process for the Adventist Health care system. Monitors utilization of services for our facilities while maximizing use of the patient’s provider benefits for their needs. Plans, directs and monitors the utilization and clinical resource management functions, as well as coordinating with other revenue cycle stakeholders to develop an integrated work flow that supports payment for clinical services provided. Recommends appropriate designation of the medical necessity of inpatient and observation cases, based on the use of established criteria sets to determine the appropriate length of stay, level of care and proper utilization of resources. Manages the denials and appeals process with third party payers and assists with development of utilization review and resource management programs based on the changing requirements or new contractual arrangements with third party payers. Serves as an organizational expert on clinical resources and utilization management, and coordinates and assists with departmental and organizational quality improvement strategies to ensure compliance with all regulatory standards. Prepares, presents and analyzes outcomes data and recommends and executes continual process and quality improvement initiatives. Trains and maintains competencies on all departmental staff and assists in planning the departments capital equipment and operations budgets.

Job Requirements:

Education and Work Experience:

• Graduate of an accredited/approved school of nursing, Bachelor’s degree in Nursing, Healthcare Administration or another relevant field: Required
• Master's Degree: Preferred
• Seven years’ experience in clinical utilization review or case management within a hospital or large health plan.: Preferred
• Five years' leadership experience: Preferred

Licenses/Certifications:

• Minimum Certification ACM or CCM certification required or completed within one year of hire Active CA RN license: Required
• Registered Nurse (RN) license in state of practice: Required
• RN - Case Manager (ACM-RN) or Certified Case Manager (CCM) or American Case Management Association (ACMA): Required

Essential Functions:

• Develops, plans and implements the operational functions of the care management resource center to align with industry best practices.
• Prepares, presents and analyzes outcomes data and recommends and executes continual process and quality improvement initiatives.
• Oversees staff including training, performance, competencies, productivity and ongoing education.
• Coordinates with other revenue cycle stakeholders to develop an integrated work flow that supports payment for clinical services provided.
• Communicates findings, opportunities and outcomes via presentations, data analysis and ongoing education to various stakeholders throughout the organization.
• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.

Adventist Health is a faith-based, nonprofit, integrated health system serving more than 90 communities on the West Coast and Hawaii with over 400 sites of care, including 26 acute care facilities, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of 37,000 includes employees, physicians and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.