Yamhill Community Care · 1 week ago
Clinical Support Specialist - Utilization Management (CSS - UM)
McMinnville, OR
Full-time
Hybrid
Entry, Mid Level
2+ years expYamhill Community Care is a nonprofit coordinated care organization dedicated to managing healthcare for Medicaid members in Yamhill County. The Clinical Support Specialist - Utilization Management (CSS-UM) will perform utilization management support duties, including processing authorization requests and collaborating with clinical staff and providers to ensure positive health outcomes for members.
CommunitiesHealth CareNon Profit
Responsibilities
Coordinates and facilitates correct identification of patient status and benefit coverage per Oregon Medicaid guidelines
Performs pre-authorizations, concurrent review, and post authorization request services necessary for adhering to administrative guidelines, policies, procedures, and timelines
Ensures documentation meets State and Federal regulatory requirements for turn-around times, notification, and service authorization decisions
Consults with providers, community partners, and colleagues to ensure all member requests are identified by the CCO
Independent receives and processes incoming requests ensuring member identification, creation of service authorization requests, and clinical documentation is present
Manages and processes case assignments for Clinical Peer Reviewers and Clinical Staff
Maintains understanding of business rules and regulatory requirements pertaining to UM processes and operations
Generates and creates community confidence in YCCO programs and services by embracing and exhibiting the Vision and Mission of YCCO
Models excellent customer service for all inquiries, incoming calls, and decision routing to appropriate person/department in a respectfully and culturally appropriate manner
Educates and ensures collaborative cross-setting communication among providers from all networks (physical, behavioral, dental, transportation, traditional health workers)
Proactively establishes trusting relationships through regular contact and consulting with professionals in the areas of oral and behavioral health, pharmacists, primary care, etc
Takes independent actions to address members’ identified needs including, but not limited to: Reviews and processing processes service authorization requests, ensures appropriate monitoring, evaluates and reports while making appropriate referrals both internally and externally to appropriate departments/resources
Represents the Plan in facilitating cross-setting communication including clinic providers, community partners, and member support teams
Tracks initial / concurrent service authorizations, denials, authorization gaps, and appeals status
Self-assigns and completes tasks as they appear in the UM tasking queue
Proactively establishes trusting relationships through regular contact, participates on Multi-Disciplinary Team, consults with other professionals in the areas of oral and behavioral health, pharmacists, primary care, etc
Responds to all inquiries with a professional manner using Department guidelines
Educates and ensures collaborative communication among providers from all networks (physical, behavioral, dental, transportation, traditional health workers)
Generates correspondence with clinical staff, providers, and members of the care team to meet turnaround time requirements
Contributes to the creation of service authorization requests and the delivery of services as aligned with identified care needs under the direction of clinical care coordination staff
Identifies and collects all required documentation as set forth by Federal, State, funding regulations, and Agency policy
Serves as a Mandatory Reporter of suspected abuse of vulnerable populations as required by policy and regulation
Maintains a high level of accuracy when processing and sharing information according to privacy regulations
Protects clients and reduces YCCO risk by modeling and following policies, regulations, and requirements of Oregon Health Authority and YCCO
Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members
Participates in the preparation and submission of regulatory and contract required deliverables
Works closely with other YCCO departments, including Health Plan Operations and Compliance to assist with audits; including the External Quality Review (EQR), as needed
Proposes and implements process improvements
Meets deadlines for completion of assigned responsibilities and projects
Maintains agreed upon work schedule with punctual, regular, and predictable attendance
Attends in person Annual Company Conference in Oregon; typically held in the fourth week of September
Demonstrates cooperation and teamwork using a professional and respectful demeanor
Provides cross-training on specific job responsibilities
Meets identified goals that contribute to departmental goals
Works collaboratively in a team and matrixed (cross-department) environment with a spirit of cooperation
Respectfully takes direction from Supervisor
Performs other duties as assigned
Qualification
Required
Minimum two (2) years' experience in healthcare setting including experience with case management, disease management, and/or quality improvement departments
Any combination of education and experience that would qualify candidate for the position
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
Ability to assess a situation and seek or determine appropriate resolution, accept managerial direction, and feedback, and tolerate and manage stress
Ability to use good judgment, takes personal initiative and uses discretion in performing job responsibilities including planning, prioritization, and organizational skills
Ability to work efficiently as a member of a care team
Ability to establish and maintain collaborative relationships with all levels of colleagues and the general public
Ability to follow policy and procedure while working independently and to seek and offer assistance when needed
Ability to work well with others, to hear and understand differing points of view, and to be able to articulate and explain situations based on perspective of client
Highly proficient in spelling, grammar, and punctuation
Knowledge of principles and procedures of record keeping and reporting
Knowledge of rules regarding mandatory reporting
Employees in this position may be subject to drug screening, as well as a physical and vaccination assessment
Possess a high degree of initiative and motivation along with the ability to effectively collaborate and plan with others
Excellent organizational skills including ability to handle multiple priorities and demands simultaneously in a dynamic work environment while maintaining high attention to detail and accuracy
Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a Matrix or shared resources across departments work model
Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook
Ability to communicate both professionally and effectively in all forms of communication
Ability to work in an environment with diverse individuals and groups
Ability to remain flexible, positive, and adaptable
Ability to work across the YCCO region and to work remotely, as needed
Preferred
Bilingual (English/Spanish)
Associates or Bachelor's in Health related field
Knowledge of Oregon Medicaid requirements prior authorization and/or utilization review services
Company
Yamhill Community Care
Yamhill Community Care (YCCO) is a Coordinated Care Organization (CCO) that serves Oregon Health Plan (OHP) members in Yamhill County, and parts of Washington and Polk counties.
51-200 employees
Funding
Current Stage
Growth StageLeadership Team
Seamus McCarthy
President and Chief Executive Officer
Company data provided by crunchbase