Manager, Utilization Review

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

• 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 individual(s) for processing.
• Creates processes and provides oversight support and monitoring of tracking and sorting reports for prior authorization requests and supporting information using current systems and processes.
• Creates processes and provides oversight support 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.
• Maintains recommends and monitors 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 organizations 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 monitor and work collaboratively with claims and provider networking department to problem solve and communicate with internal and external stakeholder of changes or improvements in processes. This include developing educational materials to be managed on the 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.
• Comply with organizations internal policies and procedures Code of Conduct Compliance Plan along with applicable Federal State and local regulations.
• Conduct interviews evaluation of staff and new-hire onboarding practices.
• Provides oversight monitoring and training on receiving HRS flexible spending requests via fax email referral and case management platforms. Includes entering requests into systems for tracking and review. Validates requests for completion and completes notices for outcomes to member and submitter.
• Provides oversight monitoring and training on payment and tracking of flexible spending requests. Maintaining documentation and completion of requests.
• Perform basic time management duties (PTO requests leave timecards etc.).
• Staff coaching and performance management as needed.
• Oversee the daily activities of team.
• In collaboration with Leadership ensure staff have daily huddle for new tasks updates and task assignment.
• Ensure coverage when staff call out and provide temporary coverage workflow to all staff.
• Ensure all team members are current with workload monitoring productivity and staffing sufficiency.
• Ensure all patient calls and emails are returned by end of business by all staff.
• Assign extra duties to staff when needed to fulfill needs of department.
• Work collaboratively with leadership and staff to ensure efficient system-wide processes are in place.
• 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 KPIs.
• Oversee the career pathing growth and performance improvement of staff.
• Complexity of duties may vary based on the level of experience education and qualifications.
• Other duties as assigned.

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

• Must have LVN or LPN
• 3-5 years in healthcare prior authorization or utilization management.
• Must have 3 years of management experience in healthcare setting.
• Proven experience leading teams in healthcare settings delivering results with impact.
• Strong proficiency in computer systemsWindows Word Excel Outlook and clinical platforms.
• Expertise in ICD-10 codes CPT codes and medical terminology.
• Exceptional organizational and communication skills to juggle priorities in a fast-paced environment.
• Analytical and critical thinking capabilities that elevate decision-making.
• A collaborative mindset to engage effectively with healthcare providers patients and insurance companies.
• Comfort working with electronic medical records (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.

• 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 or translation capabilities a plus

About Umpqua Health

At Umpqua Health were more than just a healthcare organization; were a community-driven Coordinated Care Organization (CCO) committed to improving the health and well-being of individuals and families throughout our region. Umpqua Health serves Douglas County Oregon where we prioritize personalized care and innovative solutions to meet the diverse needs of our members. Our comprehensive services include primary care specialty care behavioral health services and care coordination to ensure our members receive holistic integrated healthcare. Our collaborative approach fosters a supportive environment where every team member plays a vital role in our mission to provide accessible high-quality healthcare services. From preventative care to managing chronic conditions were dedicated to empowering healthier lives and building a stronger healthier community together. Join us in making a difference at 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.