Manager, Utilization Review

Umpqua Health • Roseburg, OR

7h • Remote

About The Position

At Umpqua Health, we're more than just a healthcare organization; we're 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, we're dedicated to empowering healthier lives and building a stronger, healthier community together. Join us in making a difference at Umpqua Health.

POSITION PURPOSE
The Manager of Utilization Review provides support to Umpqua Health Alliance (UHA) for the intake, processing of and finalization of all prior authorizations received by Medical Management in compliance with regulatory requirements.

Requirements

• 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 systems—Windows, 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.
• Must reside in Oregon.

Nice To Haves

• 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

Responsibilities

• 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 organization’s 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 organization’s 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 KPI's.
• 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.

Benefits

• Generous benefit packages including PTO, Health/Vision/Dental Insurance, 401k with a company match, gym membership reimbursement, tuition reimbursement, and more.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: No Education Listed