Manager, Utilization Review

Overview

At Umpqua Health, we're a community-driven Coordinated Care Organization (CCO) committed to improving the health and well-being of individuals and families in Douglas County, Oregon. Our services include primary care, specialty care, behavioral health services, and care coordination to provide holistic, integrated healthcare. We foster a collaborative environment where every team member plays a vital role in delivering accessible, high-quality healthcare services.

Position Title: Manager, Utilization Review

Department: Utilization Management

Status: Full Time, Exempt

Schedule: Monday through Friday - 8:00am - 5:00pm

Location: Remote position (occasional travel as required)

Salary: Wage Band 18: $68,155 - $81,785

• Salary: Dependent upon skills, experience, and education.
• Benefits: Generous packages including PTO, Health/Vision/Dental Insurance, 401k with company match, gym membership reimbursement, tuition reimbursement, and more
• Position type: Full-time. Must reside in Oregon

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.

• 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 individuals for processing
• Create processes and provide oversight, support and monitoring of tracking and sorting reports for prior authorization requests and supporting information using current systems and processes
• Create processes and provide oversight 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
• Maintain, recommend, and monitor 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 collaboration with claims and provider networking to problem solve and communicate changes or improvements in processes; develop educational materials for 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
• Conduct interviews, evaluate staff, and oversee new-hire onboarding practices
• Provide oversight and training on receiving HRS flexible spending requests via fax, email, referral, and case management platforms; enter requests into systems and validate completion
• Provide oversight and training on payment and tracking of flexible spending requests; maintain documentation
• Perform basic time management duties (PTO requests, leave, timecards, etc.)
• Staff coaching and performance management as needed
• Oversee daily activities of the team and ensure coverage during staff absences
• In collaboration with…