Utilization Management Manager – Remote Nonprofit Role

Primary Work Location
:
Remote (Oregon Headquarters). This position is 100% remote and open only to candidates residing in states where the organization is authorized to do business.

Authorized Remote States
:
Oregon, Arizona, Florida, Idaho, Kentucky, Maine, North Carolina, Oklahoma, Pennsylvania, Tennessee, Texas, Virginia, Washington.

Department: Health Plan Operations FLSA Status: Exempt (Salaried)

Reports To: Nursing Director - RN Work Location Type: Hybrid / 100% Remote

About Us:
Yamhill Community Care is a nonprofit coordinated care organization dedicated to managing the healthcare for Medicaid members, covered under the Oregon Health Plan, in Yamhill County, as well as parts of Washington and Polk Counties. Our mission is to improve the quality of life of the communities we serve by coordinating effective care.

Learn more about Yamhill Community Care:

Summary

This position is responsible for the successful oversight and management of the Utilization Management (UM) team and associated activities and deliverables. Working collaboratively across Yamhill Community Care (YCCO) teams as well as with external partners and the community. This position will manage the day-to-day operations and direct supervision of UM staff. This UM Manager monitors the effectiveness / outcomes of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed.

• Works collaboratively with the Chief of Health Plan Operations, Nursing Director–RN to ensure the UM program meets Oregon Administrative Rules (OARs), contractual obligations, and organizational policies.
• Oversees and supports UM processes to ensure effective and compliant UM reviews that meet State and Federal rules and regulations.
• Collaborates with the YCCO Chief Medical Officer (CMO) and/or Associate Medical Director to facilitate peer-to-peer review, developing and interpreting medical necessity policies and their application, and other review activities.
• Effectively and efficiently manages a diverse workforce in a fast-paced, dynamic regulatory environment.
• Leads process improvement initiatives within the UM program, working with a variety of departments and multi-disciplinary staff.

Job Duties

• Ensures integrated UM program activities meet OARs and contractual obligations. Includes, but is not limited, to the following:
• Develops and oversees UM policies and processes working in collaboration with the Nursing Director - RN, the CMO, and the Associate Medical Director to ensure that UM activities, documentation, and reporting supports quality, timely, and compliant deliverables.
• Collaborates and coordinates across providers and healthcare settings to ensure optimal quality outcomes.
• Ensures support for the YCCO CMO and/or Associate Medical Director in the provision of peer-to-peer and other review activities.
• Seeks consultation with CMO, the Associate Medical Director and/or Nursing Director–RN, as needed, to support quality of care.
• Refers UM issues to the Nursing Director–RN and/or CMO, Associate Medical Director or the CMO in a timely manner and monitors the issue until it is resolved.
• Collaborates with the Care Management team to support members’ successful transitions between levels of care.
• Ensures member and other communications and notices are composed in a manner consistent with regulatory standards.
• Collaborates with internal and external entities to support the successful resolution of medical necessity and other reviews.
• Provides consultation regarding UM to physicians and other colleagues within the Yamhill Health system working in collaboration with the CMO, Nursing Director–RN and Provider Relations.
• Ensures that UM staff are consistent in conducting medical necessity review/appeals to ensure appropriateness of care.
• Documents UM, quality, and risk concerns and refers to appropriate departments as applicable for follow-up.

Supervision of Utilization Management Team

• Communicates with team members daily/weekly/monthly, as appropriate, to support individual staff and the team’s ability to meet program deliverables and outcomes.
• Support…