Health Plan Utilization Management Manager – Oregon Medicaid

Yamhill Community Care; McMinnville (OR); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Yamhill Community Care is seeking a UM Manager to oversee the Utilization Management team and ensure regulatory compliance with Oregon rules. You will supervise staff, coordinate with the Nursing Director–RN and CMO, and drive process improvements to optimize medical necessity reviews and outcomes.

The role requires leadership experience in UM, knowledge of Medicaid/Medicare rules, and strong collaboration across departments in a fast-paced health plan environment.

Qualifications

• Bachelor’s degree in Nursing or healthcare field required.
• Two or more years leading Utilization Management programs and three or more years supervisory experience.
• Oregon Medicaid experience is required or equivalent experience.

Responsibilities

• Oversee the UM program to meet Oregon Administrative Rules (OARs) and contractual obligations.
• Lead the Utilization Management team and provide direction and coaching.
• Collaborate with CMO and Nursing Director–RN on medical necessity policies and reviews.
• Lead performance improvement initiatives and ensure regulatory compliance.

Skills

Regulatory knowledge of UM rules

Medicaid/Medicare UM regulations

Process improvement

Analytical skills

Education

Bachelor’s degree in Nursing or healthcare field

Master’s degree in Nursing or Healthcare

Tools

McKesson InterQual

Job description

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.

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.
• Supports team’s adherence to Policies and Procedures set forth by the organization and State regulations/contract.
• 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.
• 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.

Participate in Performance Improvement Activities

• Uses data to drive decisions and plans / implements performance improvement strategies related to UM activities.
• Identifies and facilitates resolution of system process issues impeding UM functions.
• Participates in development, implementation, teaching, evaluation, and revision of departmental standards related to UM.
• 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 needed for optimal performance.
• 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.
• 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.
• 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.
• Attends 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.
• 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.
• 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 (cross-department) or shared resources across departments work model with a spirit of cooperation.
• Excellent computer skills, using software tools for analysis and presentation of UM related data

Supervisory Responsibilities

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.

Education & Experience

Required:

• Bachelor’s degree in Nursing or other Healthcare related field, such as Behavioral Health, Healthcare Administration,
• Three (3+) years of supervisory or team leadership experience,
• Two (2+) years of leadership in a Utilization Management program,
• Two (2+) years of Oregon Medicaid 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),
• 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).