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)

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:  click here

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

1. 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.
2. Oversees and supports UM processes to ensure effective and compliant UM reviews that meet State and Federal rules and regulations.
3. 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.
4. Effectively and efficiently manages a diverse workforce in a fast-paced, dynamic regulatory environment. 
5. 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.
• Ensures effective management of work queues and other UM deliverables.
• Ensures performance of all necessary UM-related reviews within required timelines or earlier as directed.
• 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.
• Monitors and works with staff to be compliant with deliverables, required timelines, and other performance elements.
• Supports onboarding, training, and education across teams.
• Supports team’s adherence to Policies and Procedures set forth by the organization and State regulations/contract.
• Serves as a resource person for UM staff and others to ensure consistent and accurate UM determinations.
• Ensures staff respond to all requests appropriately, accurately, and timely according to policies.
• Participates in the orientation of new department staff specific to UM.
• Develops and provides individualized UM-related education as needed.

Oversight of Utilization Management Program Deliverables

• Participates in the preparation and submission of regulatory and contract required deliverables.
• Ensures that UM documentation is entered in a clear, organized, and timely manner that is compliant with OAR / ORS and contractual requirement.
• Develops and maintains UM policies and procedures.
• Ensures ongoing compliance monitoring of UM functions.
• Completes assignments, monthly statistics, and all other required reporting.
• Monitors UM for quality and risk concerns. 
• Refer to appropriate departments as applicable.
• Facilitates the necessary updates of UM related screening tools and resources, creation of training tools, and providing training to UM staff.
• Prepares succinct, written UM related documentation as directed by the Nursing Director-RN.
• Participates in, and/or leads, assigned Committee and UM activities. 
• Ensures documentation of activities are entered in a clear, concise, organized, and timely manner.

Participate in Performance Improvement Activities

• Uses data to drive decisions and plans / implements performance improvement strategies related to UM activities.
• Creates reports, displaying data and providing narrative analysis, to a variety of audiences.
• Identifies and facilitates resolution of system process issues impeding UM functions. 
• Identifies and resolves delays and obstacles as appropriate.
• Leads and participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff.
• Participates in development, implementation, teaching, evaluation, and revision of departmental standards related to UM.

Management & Leadership

• Champions the organization's mission, vision, and goals.
• Inspires and motivates employees, aligns teams with company objectives, and helps maintain a positive company culture.
• Communicates clear expectations, goals, and standards to all department staff to ensure alignment and accountability. 
• Ensures staff have the necessary training, equipment, tools, and resources to perform their roles effectively by working with Human Resources.
• Analyzes and monitors staff productivity and work quality, reorganizing and distributing work assignments needed for optimal performance.
• Provides consistent, fair, and supportive supervision of all assigned department staff.
• Partners with Supervisor and Human Resources to manage human resource functions such as interviewing, hiring, onboarding, training employees, conflict resolution, and performance management.
• Meets YCCO’s employee coaching standards through consistent 1:1 (one on one) and performance coaching meetings with all department assigned staff.
• Provides department with ongoing understanding of the transformation, strategic plans and operational direction of YCCO.
• Provides staff with the training, tools, and resources necessary to carry out assigned work.
• Analyzes staffing needs and reorganizes work and assignments, as needed.
• Supervises assigned unit staff in a consistent manner.
• Evaluates unit employees’ performance both informally and formally and takes corrective action in collaboration with the Nursing Director–RN and Human Resources to address areas of opportunity.

Essential Department & Organizational Functions

• Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members.
• Participates in the preparation and submission of regulatory and contract required deliverables.
• Works closely with other YCCO departments, including Compliance to assist with audits; including the External Quality Review (EQR), as needed.
• Supports the organization’s quality improvement goals, including contributing to quality incentive programs and supporting measurable progress on quality metrics that advance the health and well-being of the communities we serve.
• Proposes and implements process improvements.
• Meets deadlines for completion of assigned responsibilities and projects.
• Maintains agreed upon work schedule with punctual, regular, and predictable attendance.
• Attends in person Annual Company Conference in Oregon; typically held in the fourth week of September.
• Demonstrates cooperation and teamwork using a professional and respectful demeanor.
• Provides cross-training on specific job responsibilities.
• Meets identified goals that contribute to departmental goals.
• Respectfully takes direction from Supervisor.
• Other duties as assigned.

Knowledge, Skills, & Abilities

• Demonstrate a working knowledge of regulatory and survey standards (Medicare, Medicaid, Joint Commission, and NCQA).
• Demonstrate a working knowledge of disease, including mental illness and addiction, and age specific impact.
• Demonstrate a working knowledge of approved status determination criteria and apply consistently according to interrater reliability techniques.
• Demonstrates a working knowledge of rapid-cycle process improvement.
• Apply advanced critical thinking and conflict resolution skills using creative approaches.
• Ability to utilize negotiation skills, which effectively promote constructive solutions.
• Work collaboratively and professionally across YCCO teams as well as with external partners and the community.
• Excellent interpersonal communication, problem-solving, and conflict resolution skills.
• Knowledgeable in areas of: Medicare and Medicaid UM regulations, McKesson InterQual, Medicare. Inpatient Only List, HERC (Health Evidence Review Commission) Guidelines, RAC (Recover Audit Contractors), QIO (Quality Improvement Organizations), MAC (Medical Administrative Contractors), and Denial Management.
• Demonstrate positive and professional written, verbal, and nonverbal communication skills.
• Excellent organizational skills including ability to handle multiple priorities and demands simultaneously in a dynamic work environment while maintaining high attention to detail and accuracy.
• Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a Matrix (cross-department) or shared resources across departments work model with a spirit of cooperation.
• Excellent computer skills, including Microsoft Windows, Word, Excel, Outlook and other software tools for analysis and presentation of UM related data.
• Ability to communicate both professionally and effectively in all forms of communication.
• Ability to work in an environment with diverse individuals and groups.
• Ability to remain flexible, positive, and adaptable. Ability to work across the YCCO region and to work remotely, as needed.

Supervisory Responsibilities

Directly supervises employees in the Utilization Management program. Carries out supervisory responsibilities in accordance with the organization’s policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential duties.

Education & Experience

Required:

• Bachelor’s degree in Nursing or other Healthcare related field, such as Behavioral Health, Healthcare Administration,
• Three (3+) years of experience supervising or leading teams,
• Two (2+) years of Utilization Management experience.

     OR:

• Any combination of education and experience that would qualify candidate for the position.

Preferred:

• Master’s degree in Nursing or other Healthcare related field,
• Five (5) years of relevant clinical nursing or healthcare related experience,
• Experienced in physical and behavioral health integration,
• Experience with Coordinated Care Organization (CCO) / Medicaid Managed Care,
• Three (3+) years of experience with Utilizations Management,
• Equivalent combination of education and experience will be considered.

Certificates, Licenses, and/or Registrations

Preferred:

• ACM (Accredited Case Manager) through AMCA (American Case Management Association),
• CCM (Certified Case Manager) CCMC (Commission for Case Manager Certification),
• Board certification in Nursing Case Management (RN-BC) through ANCC (American Nurses Credentialing Center),
• CPHQ (Certified Professional in Health Care Quality) through NAHQ (National Association of Health Care Quality).

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this position. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this position. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential duties.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit, stand, walk, use hands and fingers, handle or feel, and reach with hands and arms. The employee is occasionally required to climb or balance, stoop, kneel, crouch or crawl. The employee may occasionally need to lift and/or move up to 25 pounds. 

This position operates in a professional office environment and requires frequent use of standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Specific vision abilities required by this job include close vision, color vision, distance vision, depth perception, and ability to adjust focus. The noise level in the work environment is usually moderate.

This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.