Health Plan Utilization Management RN Manager

Clinical Management Consultants; Eugene (OR); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Clinical Management Consultants seeks a Health Plan Utilization Management Manager for the Willamette Valley near Eugene. You will lead a team responsible for timely, well-informed care decisions, collaborating with physicians, care managers, and provider relations staff.

The role entails supervising daily UM operations, optimizing processes, and ensuring consistency with medical necessity criteria. A bachelor's in nursing or related healthcare field plus leadership experience is required;

Qualifications

• Bachelor's degree in nursing or a related healthcare field.
• At least three years of supervisory or team leadership experience.
• Two years of Utilization Management program leadership experience.
• Two years of Oregon Medicaid experience.
• Master's degree, Medicaid managed care experience, or integrated physical and behavioral health background preferred.

Responsibilities

• Oversee daily UM review operations and supervise the UM team.
• Balance workloads and monitor turnaround times.
• Coach staff on applying medical necessity criteria.
• Facilitate peer-to-peer reviews with medical leadership.
• Drive program improvements to meet Oregon Medicaid requirements.

Skills

Supervisory experience

Team leadership

Utilization management knowledge

Oregon Medicaid experience

Education

Bachelor's degree in nursing or related healthcare field

Master's degree (preferred)

Job description

Bring your Oregon Medicaid experience to a Health Plan Utilization Management Manager role in Oregon's Willamette Valley, near Eugene, where you'll lead the team that helps members get timely, well-informed decisions about their care.

At this community health plan, the Utilization Management Manager works closely with the people on both sides of a review. Treating providers need to know what clinical information will help resolve a request, and members need a clear explanation of a decision that affects their care. You'll work with physician leaders, care managers, and provider relations staff to address those needs, particularly when a member is moving between levels of care or has both physical and behavioral health needs.

Reporting to the Nursing Director, the UM Manager oversees daily review operations and directly supervises the utilization management team. You'll balance workloads, monitor turnaround times, and coach staff on applying medical necessity criteria consistently across reviews and appeals. When a complex case calls for physician input, you'll work with medical leadership to facilitate peer-to-peer review. Regular one-on-one coaching also gives you time to work through difficult cases with reviewers and understand where they need more guidance.

The Utilization Management Manager has the authority to improve how the program works. If requests repeatedly stall at the same point, you'll examine the data with staff, identify the cause, and test a change. That might mean updating a screening tool, clarifying when to escape a case, or developing training around a difficult review criterion. You'll track whether the change improves timeliness and quality, share the results with leadership, and keep the program aligned with Oregon Medicaid requirements.

The health plan seeks a UM leader with a bachelor's degree in nursing or a related healthcare field and at least three years of supervisory or team leadership experience. Candidates should bring at least two years of UM program leadership and two years of Oregon Medicaid experience. Equivalent combinations of education and experience will be considered. A master's degree, Medicaid managed care experience, or a background in integrating physical and behavioral healthcare is preferred.

The Utilization Management Manager role offers hybrid or fully remote work, with no routine weekend work and a required annual in-person conference in Oregon. For those who call the Willamette Valley home, the Salem region offers riverfront paths for an after-work walk, farm stands and tasting rooms to explore on weekends, and easy options for a day trip to the Oregon Coast or the Cascades.