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Corporate Director, EHP Clinical Operations in Ontario, CA at Prime Healthcare Services Inc

Date Posted: 6/12/2019

Job Snapshot

  • Employee Type:
  • Location:
    3300 East Guasti Road
    Ontario, CA
  • Job Type:
  • Experience:
    At least 5 year(s)
  • Date Posted:

Job Description


The Corporate Director of Employee Health Plan Clinical Operations provides comprehensive oversight of the Utilization Review process for the self-insured Employee Health Plans, according to the EPO Plan Documents and any other applicable documents. Provides leadership and supervision to utilization review department, provides interprofessional collaboration with facility based case managers and discharge planners. Integrates and coordinates services using continuous quality improvement initiatives to promote positive patient outcomes. The Corporate Director of EHP Clinical Operations interacts with all aspects of the Employee Health Plans Team, including Claims and Customer Service, to provide guidance on complex Authorizations, Referrals, Denials and Appeals.


This position is required to be onsite at the Prime Healthcare Corporate HQ full-time.

Required qualifications:

  1. Minimum BA/BS degree in Nursing, Healthcare Administration, or another relevant field
  2. A minimum of five (5) years’ experience in Clinical Utilization Review or Case Management with a large Health Plan
  3. An active CA Registered Nurse license
  4. Current BCLS (AHA) certificate upon hire and maintain current
  5. Analytical ability for problem identification and assessment and evaluation of data/statistics obtained from an on-going review process
  6. Knowledge of Milliman Care Guidelines, InterQual Criteria, and CMS Criteria
  7. Knowledge of self-funded health plans, ERISA and HIPAA guidelines
  8. Experience and knowledge in intermediate computer skills (i.e. Microsoft Word, Excel)

Preferred qualifications:

  1. Master’s Degree in Nursing, Healthcare Administration, or another relevant field
  2. Professional Certification in Case Management


We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.  EEO is the Law: