Utilization Management Manager – Remote Nonprofit Job Boise Idaho USA,Management

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)

Division: Utilization Management Physical Strength: Light (L)

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

Supervisory Role: Yes Occasional Weekend Work: No

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. Beyond healthcare, we also provide an Early Learning Hub, supporting families and children with essential resources and programs for early childhood development.

Together, we're building a unified healthy community that celebrates physical, mental, emotional, spiritual, and social well-being.

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.

The UM Manager will manage a team that supports the triple aim and positive outcomes for YCCO members.

Essential Duties

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…