Manager Utilization Review

Umpqua Health; Remote; USD 68,000 - 82,000; Full time

Job summary

A community-driven healthcare organization is seeking a Manager of Utilization Review to oversee the intake and processing of prior authorizations. This full-time role requires strong management skills and experience in healthcare. The ideal candidate will have a background in utilization management, proficiency with relevant software, and the ability to lead a team effectively. Benefits include generous PTO, health insurance, and a competitive salary range.

Benefits

Generous benefits including PTO

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.
• Strong proficiency with Windows, Word, Excel, and Outlook.

Responsibilities

• Manage intake and processing of prior authorizations received.
• Supervise department telephone coverage and ensure timely responses.
• Conduct audits and identify process improvement opportunities.

Skills

LVN or LPN

Healthcare prior authorization

Management experience

ICD-10 and CPT codes proficiency

Organizational skills

Communication skills

Analytical skills

EMR systems knowledge

Education

LVN or LPN qualification

Tools

MS Office suite

Job description

Overview

About Umpqua Health

Umpqua Health is a community-driven Coordinated Care Organization (CCO) serving Douglas County, Oregon. We prioritize personalized care and innovative solutions to meet the diverse needs of our members. Our services include primary care, specialty care, behavioral health, and care coordination to provide holistic, integrated healthcare. We strive to empower healthier lives and a stronger community.

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 is dependent upon skills, experience, and education.
• Generous benefits including PTO, Health/Vision/Dental Insurance, 401k with company match, gym membership reimbursement, tuition reimbursement, and more
• Full-time position. Must reside in Oregon

Position Purpose

The Manager of Utilization Review provides support to Umpqua Health Alliance (UHA) for the intake, processing, 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 related to prior authorization processes
• Manage receipt of documentation from multiple sources on a daily basis (appeals, grievances, prior authorizations)
• Identify incoming documentation requests and redistribute to appropriate individuals for processing
• Create processes and provide oversight for tracking and sorting reports for prior authorization requests and supporting information
• Create processes and provide oversight for timely notification of prior authorization determinations
• Supervise department telephone coverage with individual login and availability
• Monitor and ensure timely responses to internal and external inquiries regarding prior authorizations
• Support the Appeals & Grievances Coordinator with questions and processing for PA upheld appeals
• Participate in trainings, audits, and meetings as required
• Maintain and monitor regulations and procedures; review daily reports
• Develop and approve training materials; update policies and procedures
• Lead internal and external reporting; train and monitor staff performing these functions
• Ensure compliance with organizational policies, Code of Conduct, Compliance Plan, and applicable laws
• Oversee onboarding and training for new staff and cross-departmental staff
• Conduct audits and identify process improvement opportunities
• Collaborate with claims and provider networks to communicate changes or improvements; develop educational materials for website, newsletters, and trainings
• Assist management with administrative tasks and communications
• Analyze reports and write narratives
• Participate in staff interviews, evaluations, and onboarding
• Oversee processing of flexible spending requests, including validation and notifications to members and submitters
• Monitor time management duties (PTO, leave, timecards)
• Coach and manage performance; oversee daily team activities and coverage
• Coordinate daily huddles for task updates and assignments; ensure workload balance and timely responses to patient calls and emails
• Create and update workflows and operating procedures; support policy development
• Understand CCO regulations with OHA contracts; support contract deliverables and KPIs
• Foster staff career development and performance improvement
• Other duties as assigned

Challenges

• Working with diverse personalities while maintaining consistent communication
• Satisfying needs in a fast-paced environment

Minimum Qualifications

• Must have LVN or LPN
• 3–5 years in healthcare prior authorization or utilization management
• 3+ years of management experience in a healthcare setting
• Proven experience leading healthcare teams with measurable results
• Strong proficiency with Windows, Word, Excel, Outlook, and clinical platforms
• Expertise in ICD-10, CPT codes, and medical terminology
• Excellent organizational and communication skills in a fast-paced environment
• Analytical and critical thinking abilities; collaborative mindset
• Experience with EMR systems and utilization management software
• No suspension or debarment from participation in federal health care programs
• Proficient in MS Office suite

Preferred Qualifications

• Experience considering impacts on diverse communities in technical analysis
• Experience working on diverse teams with different communication styles
• Bi-lingual translation capabilities a plus

Equal Opportunity

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 and business needs, 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 applicable law.

Notes

All references to internal systems, policies, and procedures should be understood as currently implemented by Umpqua Health. This posting is for job purposes and reflects current requirements as of date of posting.