Manager Utilization Review

Nashville Public Radio; Remote; USD 68,000 - 82,000; Full time

Job summary

A healthcare organization in Oregon is looking for a Manager of Utilization Review. The role is responsible for processing prior authorizations and leading a team while ensuring compliance with regulations. Candidates should have an LVN or LPN and at least 3-5 years of relevant experience in healthcare prior authorization. The position offers a competitive salary along with robust benefits such as health insurance, PTO, and tuition reimbursement. Occasional travel may be required.

Benefits

Health/Vision/Dental Insurance

401k with company match

Gym membership reimbursement

Tuition reimbursement

Qualifications

• 3-5 years in healthcare prior authorization or utilization management experience.
• 3+ years of management experience in a healthcare setting.
• Proficiency in ICD-10 codes, CPT codes, and medical terminology.

Responsibilities

• Manage the intake and processing of prior authorizations.
• Oversee support for Utilization Review and Care Coordination.
• Conduct trainings and audits within the department.

Skills

Healthcare prior authorization

Team leadership

Communication skills

Analytical thinking

Organizational skills

Education

LVN or LPN

Tools

Windows

Word

Excel

Outlook

EMR systems

Job description

Overview

At Umpqua Health, we're a community-driven Coordinated Care Organization (CCO) committed to improving the health and well-being of individuals and families in Douglas County, Oregon. Our services include primary care, specialty care, behavioral health services, and care coordination to provide holistic, integrated healthcare. We foster a collaborative environment where every team member plays a vital role in delivering accessible, high-quality healthcare services.

Position

Position Title: Manager, Utilization Review

Department: Utilization Management

Status: Full Time, Exempt

Schedule: Monday through Friday - 8:00am - 5:00pm

Location: Remote position (occasional travel as required)

Salary: Wage Band 18: $68,155 - $81,785

• Salary: Dependent upon skills, experience, and education.
• Benefits: Generous packages including PTO, Health/Vision/Dental Insurance, 401k with company match, gym membership reimbursement, tuition reimbursement, and more
• Position type: Full-time. Must reside in Oregon

Position Purpose

The Manager of Utilization Review provides support to Umpqua Health Alliance (UHA) for the intake, processing of and finalization of all prior authorizations received by Medical Management in compliance with regulatory requirements.

Essential Job Responsibilities

• Provide support for Utilization Review and Care Coordination as related to the prior authorization process
• Manage the receipt of documentation through multiple sources on a daily basis including appeals, grievances, and prior authorizations
• Identify incoming documentation requests and redistribute to appropriate individuals for processing
• Create processes and provide oversight, support and monitoring of tracking and sorting reports for prior authorization requests and supporting information using current systems and processes
• Create processes and provide oversight and monitoring of timely notification of prior authorization determinations
• Supervisors’ daily management of department telephone coverage with individual login and availability
• Monitor and ensure research and responses to requests from internal and external customers regarding prior authorizations are completed
• Provide support to the Appeals & Grievances Coordinator as needed through phone coverage, member and provider process questions, fax, and email support, and ensuring PA for upheld appeals are entered correctly for claims payment
• Conduct and participate in department trainings, audits, and meetings as required
• Maintain, recommend, and monitor regulations and procedures
• Review compliance of daily reports
• Develop and approve training documents and participate in updates for policies and procedures
• Lead internal and external reporting, and train and monitor staff performing these functions
• Comply with organization’s internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations
• Oversee, monitor, and ensure new and cross-departmental staff training and onboarding procedures are current and completed
• Conduct high-level audits and other investigatory activities to identify and rectify process improvement opportunities
• Oversee collaboration with claims and provider networking to problem solve and communicate changes or improvements in processes; develop educational materials for UHA website, provider newsletter, talking points, and department trainings
• Assist manager and director with administrative support tasks, such as meetings, employee engagement opportunities and communications
• Create, evaluate and analyze reports to write reports and narratives
• Conduct interviews, evaluate staff, and oversee new-hire onboarding practices
• Provide oversight and training on receiving HRS flexible spending requests via fax, email, referral, and case management platforms; enter requests into systems and validate completion
• Provide oversight and training on payment and tracking of flexible spending requests; maintain documentation
• Perform basic time management duties (PTO requests, leave, timecards, etc.)
• Staff coaching and performance management as needed
• Oversee daily activities of the team and ensure coverage during staff absences
• In collaboration with leadership, ensure daily huddles for new tasks, updates, and task assignment
• Ensure all patient calls and emails are returned by end of business by all staff
• Assign extra duties to staff as needed to fulfill department needs
• Work with leadership to ensure efficient, system-wide processes
• Create and update workflows and operating procedures as needed
• Make recommendations and assist with department policies
• Understand CCO regulations with OHA contract
• Assist leadership with accurate and timely completion of contract deliverables and internal KPI’s
• Oversee career pathing, growth, and performance improvement of staff
• Complexity of duties may vary based on experience, education, and qualifications
• Other duties as assigned

Challenges

• Working with a variety of personalities, maintaining a consistent and fair communication style
• Satisfying the needs of a fast-paced and challenging company

Minimum Qualifications

• Must have LVN or LPN
• 3-5 years in healthcare prior authorization or utilization management
• 3+ years of management experience in healthcare setting
• Proven experience leading teams in healthcare settings, delivering results with impact
• Strong proficiency in computer systems—Windows, Word, Excel, Outlook, and clinical platforms
• Expertise in ICD-10 codes, CPT codes, and medical terminology
• Outstanding organizational and communication skills to juggle priorities in a fast-paced environment
• Analytical and critical thinking capabilities that elevate decision-making
• Collaborative mindset to engage effectively with healthcare providers, patients, and insurers
• Comfort working with EMR systems and utilization management software
• No suspension/exclusion/debarment from participation in federal health care programs (e.g. Medicare/Medicaid)
• Proficient computer skills, including MS Office suite

Preferred Qualifications

• Experience considering the impacts of the work on multiple communities, including communities of color, in technical analysis
• Experience working on a diverse team with different communication styles
• Bi-lingual translation capabilities a plus

About Umpqua Health

Umpqua Health is an equal opportunity employer that embraces individuals from all backgrounds. We prohibit discrimination and harassment of any kind, ensuring that all employment decisions are based on qualifications, merit, and the needs of the business.

Our dedication to fairness and equality extends to all aspects of employment, including hiring, training, promotion, and compensation, without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other protected category under federal, state, or local law.

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