Utilization Management Manager – Remote Nonprofit Role

reputed company Work Location: Remote (reputed company reputed company). This position is reputed company and reputed company only to candidates residing in states where the organization is authorized to do business. Authorized Remote States: reputed company, reputed company, Florida, Idaho, Kentucky, Maine, reputed company Carolina, Oklahoma, reputed company, Tennessee, Texas, Virginia, Washington. Department: Health Plan Operations FLSA Status: Exempt (Salaried) Division: Utilization Management Physical Strength: reputed company (L) Reports To: Nursing Director - RN Work Location Type: Hybrid / reputed company Supervisory Role: reputed company Occasional Weekend Work: No reputed company: reputed company is a nonprofit coordinated care organization dedicated to managing the reputed company for reputed company members, covered under the reputed company Health Plan, in Yamhill County, as reputed company as parts of Washington and Polk Counties. Our mission is to improve the reputed company of life of the communities we serve by coordinating effective care. Learn more about reputed company: click here reputed company This position is responsible for the successful reputed company and management of the Utilization Management (UM) team and associated activities and deliverables. Working collaboratively across reputed company (YCCO) teams as reputed company as with reputed company partners and the community. This position will manage the day-to-day operations and reputed company supervision of UM staff. This UM Manager monitors the effectiveness / reputed company of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement reputed company as needed. Essential Duties • Works collaboratively with the Chief of Health Plan Operations, Nursing Director–RN to ensure the UM program meets reputed company Administrative Rules (OARs), contractual obligations, and organizational policies. • Oversees and supports UM processes to ensure effective and compliant UM reviews that meet State and Federal rules and regulations. • Collaborates with the YCCO Chief Medical Officer (CMO) and/or Associate Medical Director to facilitate peer-to-peer review, developing and interpreting medical necessity policies and their application, and other review activities. • Effectively and reputed company manages a diverse workforce in a fast-paced, dynamic regulatory environment. • Leads process improvement initiatives reputed company the UM program, working with a reputed company of departments and multi-disciplinary staff. Job Duties • Ensures integrated UM program activities meet OARs and contractual obligations. Includes, but is not limited, to the following: • Develops and oversees UM policies and processes working in collaboration with the Nursing Director - RN, the CMO, and the Associate Medical Director to ensure that UM activities, documentation, and reporting supports reputed company, reputed company, and compliant deliverables. • Collaborates and coordinates across providers and reputed company settings to ensure reputed company reputed company reputed company. • Ensures support for the YCCO CMO and/or Associate Medical Director in the provision of peer-to-peer and other review activities. • Seeks consultation with CMO, the Associate Medical Director and/or Nursing Director–RN, as needed, to support reputed company of care. • Refers UM issues to the Nursing Director–RN and/or CMO, Associate Medical Director or the CMO in a reputed company manner and monitors the issue until it is resolved. • Collaborates with the Care Management team to support members’ successful transitions between reputed company of care. • Ensures member and other communications and notices are composed in a manner consistent with regulatory standards. • Collaborates with reputed company entities to support the successful reputed company of medical necessity and other reviews. • Provides consultation regarding UM to physicians and other colleagues reputed company the Yamhill Health reputed company working in collaboration with the CMO, Nursing Director–RN and Provider Relations. • Ensures that UM staff are consistent in conducting medical necessity review/appeals to ensure appropriateness of care. • Documents UM, reputed company, and risk concerns and refers to appropriate departments as applicable for follow-up. Supervision of Utilization Management Team • Communicates with team members daily/weekly/monthly, as appropriate, to support individual staff and reputed company’s ability to meet program deliverables and reputed company. • Supports team’s adherence to Policies and Procedures set forth by the organization and State regulations/contract. • Ensures staff respond to reputed company requests appropriately, accurately, and reputed company according to policies. • Participates in the orientation of new department staff specific to UM. • Develops and provides individualized UM-reputed company education as needed. reputed company of Utilization Management Program Deliverables • Participates in the preparation and submission of regulatory and contract required deliverables. • Ensures that UM documentation is entered in a reputed company, organized, and reputed company manner that is compliant with OAR / ORS and contractual requirement. • Develops and maintains UM policies and procedures. • Facilitates the necessary updates of UM reputed company screening tools and resources, creation of training tools, and providing training to UM staff. • Prepares succinct, written UM reputed company documentation as directed by the Nursing Director-RN. • Participates in, and/or leads, assigned Committee and UM activities. Participate in Performance Improvement Activities • Uses data to reputed company reputed company and plans / implements performance improvement strategies reputed company to UM activities. • Identifies and facilitates reputed company of reputed company process issues impeding UM functions. • Participates in development, implementation, teaching, evaluation, and revision of departmental standards reputed company to UM. Management & Leadership • Inspires and motivates employees, aligns teams with company objectives, and helps maintain a reputed company company culture. • Analyzes and monitors staff productivity and work reputed company, reorganizing and distributing work assignments needed for reputed company performance. • Partners with Supervisor and reputed company to manage reputed company resource functions such as interviewing, hiring, reputed company, training employees, conflict reputed company, and performance management. • Meets YCCO’s employee coaching standards through consistent 1:1 (one on one) and performance coaching meetings with reputed company department assigned staff. • Evaluates unit employees’ performance both informally and formally and takes corrective reputed company in collaboration with the Nursing Director–RN and reputed company to address areas of opportunity. Essential Department & Organizational Functions • Works to cultivate and reputed company inclusive and reputed company services, and working relationships with diverse reputed company of employees, community partners, and community members. • Works closely with other YCCO departments, including Compliance to assist with audits; including the reputed company reputed company Review (EQR), as needed. • Supports the organization’s reputed company improvement goals, including contributing to reputed company incentive programs and supporting measurable reputed company on reputed company metrics that advance the health and reputed company-being of the communities we serve. • Attends in person Annual Company Conference in reputed company; typically held in the reputed company week of September. • Provides cross-training on specific job responsibilities. • Respectfully takes direction from Supervisor. • Other duties as assigned. Knowledge, Skills, & Abilities • Demonstrate a working knowledge of regulatory and survey standards (Medicare, reputed company, reputed company, and reputed company). • Demonstrate a working knowledge of disease, including mental illness and addiction, and age specific reputed company. • Demonstrate a working knowledge of approved status determination reputed company and apply consistently according to interrater reliability techniques. • Demonstrates a working knowledge of reputed company-cycle process improvement. • Knowledgeable in areas of: Medicare and reputed company UM regulations, reputed company InterQual, Medicare. Inpatient Only List, reputed company (Health Evidence Review Commission) Guidelines, RAC (Recover Audit Contractors), QIO (reputed company Improvement Organizations), MAC (Medical Administrative Contractors), and Denial Management. • Ability to work independently, use reputed company judgment, anticipate next steps and be proactive as part of a diverse team reputed company a reputed company (cross-department) or shared resources across departments work model with a spirit of cooperation. • Excellent computer skills, using software tools for analysis and presentation of UM reputed company data Supervisory Responsibilities Directly supervises employees in the Utilization Management program. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems. Education & Experience Required: • Bachelor’s degree in Nursing or other reputed company reputed company field, such as Behavioral Health, reputed company Administration, • Three (3+) years of experience supervising or leading teams, • Two (2+) years of Utilization Management experience. OR: • Any combination of education and experience that would qualify candidate for the position. Preferred: • Master’s degree in Nursing or other reputed company reputed company field, • Five (5) years of relevant clinical nursing or reputed company reputed company experience, • reputed company in physical and behavioral health integration, • Experience with Coordinated Care Organization (CCO) / reputed company Managed Care, • Three (3+) years of experience with Utilizations Management, • Equivalent combination of education and experience will be considered. Certificates, Licenses, and/or Registrations Preferred: • ACM (Accredited Case Manager) through AMCA (reputed company Case Management Association), • CCM (Certified Case Manager) reputed company (Commission for Case Manager Certification), • reputed company certification in Nursing Case Management (RN-BC) through ANCC (reputed company Nurses Credentialing Center), • CPHQ (Certified reputed company in Health Care reputed company) through NAHQ (National Association of Health Care reputed company). Apply tot his job Apply To this Job