Remote Health Plan Utilization Manager

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

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.