Utilization Management Manager

Summary

This position is responsible for the successful oversight and management of the Utilization Management (UM) 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.

Essential Duties

• Works collaboratively with the Chief of Health Plan Operations, Nursing Director–RN to ensure the UM program meets Oregon 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 efficiently manages a diverse workforce in a fast-paced, dynamic regulatory environment.
• Leads process improvement initiatives within the UM program, working with a variety 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 quality, timely, and compliant deliverables.
• Collaborates and coordinates across providers and healthcare settings to ensure optimal quality outcomes.
• 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 quality of care.
• Refers UM issues to the Nursing Director–RN and/or CMO, Associate Medical Director or the CMO in a timely manner and monitors the issue until it is resolved.
• Collaborates with the Care Management team to support members’ successful transitions between levels of care.
• Ensures member and other communications 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 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 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, quality, 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 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 UM 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 Nursing Director-RN.
• Participates in, and/or leads, assigned Committee and UM activities.
• Ensures documentation of activities are entered in a clear, concise, organized, and timely manner.

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

• Champions the organization's mission, vision, and goals.
• Inspires and motivates employees, aligns teams with company objectives, and helps maintain a positive company culture.
• Communicates clear expectations, goals, and standards to all department staff to ensure alignment and accountability.
• Ensures staff have the necessary training, equipment, tools, and resources to perform their roles effectively by working with Human Resources.
• Analyzes and monitors staff productivity and work quality, reorganizing and distributing work assignments needed for optimal performance.
• Provides consistent, fair, and supportive supervision of all assigned department staff.
• Partners with Supervisor and Human Resources to manage human resource functions such as interviewing, hiring, onboarding, training employees, conflict resolution, and performance management.
• Meets YCCO’s employee coaching standards through consistent 1:1 (one on one) and performance coaching meetings with all department assigned staff.
• Provides department with ongoing understanding of the transformation, strategic plans and operational direction of YCCO.
• Provides staff with the training, tools, and resources necessary to carry out assigned 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 in collaboration with the Nursing Director–RN and Human Resources to address areas of opportunity.

Essential Department & Organizational Functions

• Works to cultivate and develop inclusive and equitable services, and working relationships with