Umpqua Health · 1 day ago
Manager, Utilization Review
United States
Full-time
Remote
Mid, Senior Level
$68K/yr - $82K/yr
3+ years expUmpqua Health is a community-driven Coordinated Care Organization (CCO) committed to improving health and well-being in Douglas County, Oregon. The Manager of Utilization Review will oversee the prior authorization process, ensuring compliance with regulatory requirements while managing documentation and supporting the Utilization Review and Care Coordination teams.
Health CareHospitalTraining
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
Qualification
Required
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
Preferred
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
Benefits
Generous benefit packages including PTO
Health/Vision/Dental Insurance
401k with a company match
Gym membership reimbursement
Tuition reimbursement
Company
Umpqua Health
Umpqua Health helps improve the health and well-being of the community by delivering easily accessible and quality healthcare.
51-200 employees
Funding
Current Stage
Growth StageLeadership Team
Nancy Rickenbach
Chief Operating Officer
F. Douglas Carr
Chief Medical Officer
Company data provided by crunchbase