Clinical Support Specialist Utilization Management CSS UM

Location:
Hybrid
:
Most of the positions at YCCO are hybrid, meaning they have the flexibility to work both remotely and in-person at YCCO's office in McMinnville, OR.

Department: Health Plan Operations FLSA Status: Exempt (Salaried)

Division: Utilization Management Physical Strength: Light (L)

Reports To: Utilization Management Manager Work Location Type: Hybrid

Supervisory Role: No Occasional Weekend Work: Yes

Yamhill Community Care (YCCO) is a nonprofit coordinated care organization dedicated to managing the healthcare for Medicaid members, covered under the Oregon Health Plan, in Yamhill County, as well as parts of Washington and Polk Counties. Our mission is to improve the quality of life of the communities we serve by coordinating effective care. Beyond healthcare, we also provide an Early Learning Hub, supporting families and children with essential resources and programs for early childhood development.

Together, we're building a unified healthy community that celebrates physical, mental, emotional, spiritual, and social well-being.

Learn more about Yamhill Community Care:

The Clinical Support Specialist - Utilization Management (CSS-UM) will work in-person and remotely to perform all aspects of the outlined utilization management (UM) support duties, receiving and processing authorization requests, claim reviews, triage, and case assignments.

This position is responsible for administering assigned tasks, creating authorizations based on provider requests, collection and presentation of clinical documentation, and escalating identified member service request and issues. Working in collaboration and continuous partnership with clinical support staff, providers, and community resources in a team approach, to support the authorization and coverage of needed services that support positive health outcomes for YCCO members.

• Consults with providers, community partners, and colleagues to ensure all member requests are identified by the CCO.
• Independently 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 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…