Remote: This position has the possibility of being 100% Remote. Most of the positions at YCCO are hybrid, meaning they have the flexibility to work both remotely and/or in-person.

Department: Health Systems FLSA Status: Exempt

Reports To: Integrated Health Management, Sr. Manager Physical Strength: Light (L)

Summary

This position is responsible for the successful oversight and management of the Utilization Management team and associated activities and deliverables. Working collaboratively across Yamhill Community Care (YCCO) teams as well as with external partners and the community. This position will manage the day-to-day operations and direct supervision of UM staff. This UM Manager monitors the effectiveness/outcomes of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed. The UM Manager will manage a team that supports the triple aim and positive outcomes for YCCO members.

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Essential Duties

Job Duties

Ensure integrated Utilization Management program activities meet OARs and contractual obligations. Includes, but is not limited, to the following:

• Develops and oversees UM policies and processes to ensure that UM activities, documentation, and reporting supports quality, timely, and compliant deliverables.
• Collaborates and coordinates across providers and healthcare settings to ensure optimal quality outcomes.
• Ensures support for the YCCO Chief Medical Officer (CMO) in the provision of peer-to-peer and other review activities.
• Seeks consultation with CMO and/or Integrated Health Management (IHM) Sr. Manager, as needed, to support quality of care.
• Refers UM issues to the IHM Sr. Manager and/or CMO in a timely manner and monitors the issue until it is resolved.
• Collaborates with Care Management team to support members’ successful transitions between levels of care.
• Ensures member and other communication and notices are composed in a manner consistent with regulatory standards.
• Ensures effective management of work queues and other UM deliverables.
• Ensures performance of all necessary UM related reviews within required timelines or earlier as directed.
• Collaborates with internal and external entities in order to support the successful resolution of medical necessity and other reviews.
• Provides consultation regarding UM to physicians and other colleagues within the Yamhill Health system.
• Ensures that UM staff are consistent in conducting medical necessity review/appeals to ensure appropriateness of care.
• Documents UM, quality, and risk concerns and refer to appropriate departments as applicable for follow up.

Supervision of Utilization Management Team

• Communicates with the team members daily/weekly/monthly, as appropriate, to support individual staff and the team’s ability to meet program deliverables and outcomes.
• Monitors and works with staff to be compliant with deliverables, required timelines, and other performance elements.
• Supports onboarding, training, and education across teams.
• Supports team’s adherence to Policies and Procedures set forth by the organization and State regulations/contract.
• Serves as a resource person for UM staff and others to ensure consistent and accurate UM determinations.
• Ensures staff respond to all requests appropriately, accurately, and timely according to policies.
• Participates in the orientation of new department staff specific to UM.
• Develops and provides individualized UM-related education as needed.

Oversight of Utilization Management Program Deliverables

• Participates in the preparation and submission of regulatory and contract required deliverables.
• Ensures that Utilization Management documentation is entered in a clear, organized, and timely manner that is compliant with OAR/ORS and contractual requirement.
• Develops and maintains UM policies and procedures.
• Ensures ongoing compliance monitoring of UM functions.
• Completes assignments, monthly statistics, and all other required reporting.
• Monitors UM for quality and risk concerns. Refer to appropriate departments as applicable.
• Facilitates the necessary updates of UM related screening tools and resources, creation of training tools, and providing training to UM staff.
• Prepares succinct, written UM related documentation as directed by the IHM Sr. Manager.
• Participates in, and/or leads, assigned Committee and UM activities.
• Ensures documentation of activities are entered in a clear, concise, organized, and timely manner.
• Works closely with other YCCO departments to assist with audits and other deliverables, including the External Quality Review (EQR).

Participate in performance improvement activities

• Uses data to drive decisions and plans/implements performance improvement strategies related to UM activities.
• Creates reports, displaying data and providing narrative analysis, to a variety of audiences.
• Identifies and facilitates resolution of system process issues impeding UM functions. Identifies and resolves delays and obstacles as appropriate.
• Leads and participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff.
• Participates in development, implementation, teaching, evaluation, and revision of departmental standards related to UM.

Management & Leadership

• Trains, supervises, and evaluates performance of assigned staff.
• Provides department with ongoing understanding of the transformation, strategic plans and operational direction of YCCO.
• Ensures adherence to department and organizational standards, policies and procedures.
• Ensures performance goals, expectations and standards are clearly understood by supervised staff.
• Performs human resource functions in collaboration with Human Resources.
• Ensures program expectations and standards are clearly understood by unit staff.
• Provides staff with the training, tools, and resources necessary to carry out their work.
• Analyzes staffing needs and reorganizes work and assignments, as needed.
• Supervises assigned unit staff in a consistent manner.
• Evaluates unit employees’ performance both informally and formally and takes corrective action to address areas of opportunity.
• Performs human resource functions in collaboration with the Manager and Human Resources.

Essential Department & Organizational Functions

• Participates in the preparation and submission of regulatory and contract required deliverables.
• Works closely with other YCCO departments, including Health Plan Operations and Quality Assurance and Compliance, to assist with audits; including the External Quality Review (EQR), as needed.
• Proposes and implements process improvements.
• Meets deadlines for completion of workload.
• Maintains agreed upon work schedule.
• Provides cross-training on specific job responsibilities.
• Meets identified business goals that contribute to departmental goals.
• Maintains punctual, regular, and predictable attendance.
• Works collaboratively in a team environment with a spirit of cooperation.
• Respectfully takes direction from Supervisor.
• Other duties as assigned.

Knowledge, Skills, & Abilities

• Demonstrate a working knowledge of regulatory and survey standards (Medicare, Medicaid, Joint Commission).
• Demonstrate a working knowledge of disease, including mental illness and addiction, and age specific impact.
• Demonstrate a working knowledge of approved status determination criteria and apply consistently according to inter-rater reliability techniques.
• Demonstrate a working knowledge of rapid-cycle process improvement.
• Use Microsoft Word, Excel, PowerPoint, and other software tools for analysis and presentation of UM related data.
• Demonstrate positive and professional written, verbal and nonverbal communication skills.
• Apply advanced critical thinking and conflict resolution skills using creative approaches.
• Ability to utilize negotiation skills, which effectively promote constructive solutions.
• Work collaboratively and professionally across YCCO teams as well as with external partners and the community.
• Excellent interpersonal communication, problem-solving, and conflict resolution skills.
• Computer skills in word processing, data base management, and spreadsheet desirable.
• Knowledge in areas of: Medicare and Medicaid UM regulations, McKesson InterQual, Medicare. Inpatient Only List, HERC Guidelines, RAC, QIO, MAC, and Denial Management.
• Excellent organizational skills and ability to manage multiple tasks and timelines simultaneously, as well as to perform work with attention to detail.
• Ability to work independently, when needed, and to use sound judgment, anticipate next steps and be proactive.
• Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook.
• Ability to communicate effectively in all forms of communication.
• Ability to work in an environment with diverse individuals and groups.

Supervisory Responsibilities

Directly supervises employees in the Utilization Management. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

Education & Experience

Required:

• Bachelor’s degree in Nursing or Master’s degree in other Healthcare related field, including Behavioral Health.
• Three (3)+ years’ experience supervising or leading teams.
• Two (2)+ years Utilization Management experience.

OR:

• Any combination of education and experience that would qualify candidate for the position.

Preferred:

• Five (5) years relevant clinical nursing experience.
• Experienced in physical and behavioral health integration.
• Experience with Coordinated Care Organization (CCO)/Medicaid Managed Care.
• Three (3)+ years’ experience with Utilization Management.
• Equivalent combination of education and experience will be considered.

Certificates, Licenses, and/or Registrations

Preferred:

• ACM (Accredited Case Manager) through AMCA (American Case Management Association).
• CCM (Certified Case Manager) CCMC (Commission for Case Manager Certification).
• Board certification in Nursing Case Management (RN-BC) through ANCC (American Nurses Credentialing Center).
• CPHQ (Certified Professional in Health Care Quality) through NAHQ (National Association of Health Care Quality).

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this position. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit, stand, walk, use hands and fingers, handle or feel, and reach with hands and arms. The employee is occasionally required to climb or balance, stoop, kneel, crouch or crawl. The employee may occasionally need to lift and/or move up to 25 pounds.

This position operates in a professional office environment and requires frequent use of standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Specific vision abilities required by this job include close vision, color vision, distance vision, depth perception, and ability to adjust focus. The noise level in the work environment is usually moderate.

This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.

Additional Information about COVID-19 Vaccination Requirements

To safeguard the health of our employees and their families; our members and visitors; and the community at large, YCCO requires all employees to be fully vaccinated against COVID-19 or have an approved medical or religious accommodation as a qualification of employment.

Job candidates that receive a contingent offer of employment from YCCO must provide proof of COVID-19 vaccination, along with a completed attestation that the documentation submitted is true and correct to Human Resources Department;

OR

Submit a completed request for accommodation form due to a medical reason or sincerely held religious belief to the Human Resources Department to begin the interactive accommodation process.