Utilization Management Manager – Remote Nonprofit Role

Primary work location: Remote (Oregon Headquarters). This position is 100% remote and open only to candidates residing in authorized states: Oregon, Arizona, Florida, Idaho, Kentucky, Maine, North Carolina, Oklahoma, Pennsylvania, Tennessee, Texas, Virginia, Washington.

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.

About the Role

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 role manages the day-to-day operations and direct supervision of UM staff. The UM Manager monitors the effectiveness and outcomes of the UM program, identifies and applies appropriate metrics, evaluates data, reports results, and designs and implements process improvement projects as needed.

Responsibilities

• Works collaboratively with the Chief of Health Plan Operations and 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, develop and interpret medical necessity policies, 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.
• Ensures integrated UM program activities meet OARs and contractual obligations, including:
  • Developing and overseeing UM policies and processes in collaboration with the Nursing Director - RN, CMO, and Associate Medical Director.
  • Collaborating and coordinating across providers and healthcare settings to ensure optimal quality outcomes.
  • Supporting the YCCO CMO and/or Associate Medical Director in peer-to-peer and other review activities.
  • Seeking consultation with CMO, Associate Medical Director, and/or Nursing Director–RN to support quality of care.
  • Referring UM issues to the Nursing Director–RN and/or CMO, Associate Medical Director, or CMO in a timely manner and monitoring resolution.
  • Collaborating with the Care Management team to support members’ successful transitions between levels of care.
  • Ensuring member and other communications and notices are composed in a manner consistent with regulatory standards.
  • Collaborating with internal and external entities to support the successful resolution of medical necessity and other reviews.
  • Providing consultation regarding UM to physicians and colleagues within the Yamhill Health system.
  • Ensuring UM staff consistently conduct medical necessity reviews/appeals to ensure appropriateness of care.
  • Documenting UM, quality, and risk concerns and referring to appropriate departments for follow-up.
• Supervises the Utilization Management Team:
  • Communicates with team members daily/weekly/monthly to support individual staff and team deliverables.
  • Supports team adherence to organizational policies and state regulations/contracts.
  • 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.
• Oversees Utilization Management Program Deliverables:
  • Participates in the preparation and submission of regulatory and contract-required deliverables.
  • Ensures UM documentation is entered clearly, organized, and timely in compliance with OAR/ORS and contractual requirements.
  • Develops and maintains UM policies and procedures.
  • Facilitates updates of UM-related screening tools and resources, creates training tools, and provides 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.
• Participates in Performance Improvement Activities:
  • Uses data to drive decisions and implement performance improvement strategies related to UM activities.
  • Identifies and facilitates resolution of system process issues impeding UM functions.
  • Participates in the development, implementation, teaching, evaluation, and revision of departmental standards related to UM.
• Management & Leadership:
  • Inspires and motivates employees, aligns teams with company objectives, and helps maintain a positive company culture.
  • Analyzes and monitors staff productivity and work quality, reorganizing and distributing work assignments for optimal performance.
  • Partners with Supervisor and Human Resources to manage human resource functions such as interviewing, hiring, onboarding, training, conflict resolution, and performance management.
  • Meets YCCO’s employee coaching standards through consistent 1:1 and performance coaching meetings with all department-assigned staff.
  • Evaluates unit employees’ performance both informally and formally and takes corrective action in collaboration with the Nursing Director–RN and Human Resources.
• Essential Department & Organizational Functions:
  • Cultivates and develops inclusive and equitable services and working relationships with diverse groups of employees, community partners, and community members.
  • Works closely with other YCCO departments, including Compliance, to assist with audits such as the External Quality Review (EQR).
  • Supports the organization’s quality improvement goals, including contributing to quality incentive programs and measurable progress on quality metrics.
  • Attends the in-person Annual Company Conference in Oregon, typically held in the fourth week of September.
  • Provides cross-training on specific job responsibilities.
  • Respectfully takes direction from Supervisor.
  • Performs other duties as assigned.

Requirements

• Demonstrated working knowledge of regulatory and survey standards (Medicare, Medicaid, Joint Commission, and NCQA).
• Demonstrated working knowledge of disease, including mental illness and addiction, and age-specific impact.
• Demonstrated working knowledge of approved status determination criteria and application according to interrater reliability techniques.
• Demonstrated working knowledge of rapid-cycle process improvement.
• 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.
• Ability to work independently, use sound judgment, anticipate next steps, and be proactive as part of a diverse team within a matrix or shared-resources work model.
• Excellent computer skills, using software tools for analysis and presentation of UM-related data.

Qualifications

• Required:
  • Bachelor’s degree in Nursing or other Healthcare-related field, such as Behavioral Health or 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 the 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.
  • Experience in physical and behavioral health integration.
  • Experience with Coordinated Care Organization (CCO) / Medicaid Managed Care.
  • Three (3+) years of experience with Utilization Management.
  • Equivalent combination of education and experience.

Skills

Directly supervises employees in the Utilization Management program. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Certifications

Preferred:

• ACM (Accredited Case Manager) through AMCA (American Case Management Association).
• CCM (Certified Case Manager) through 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).