Manager, Utilization Review - Remote

Overview

At Umpqua Health, we're more than just a healthcare organization; we're a community-driven Coordinated Care Organization (CCO) committed to improving the health and well-being of individuals and families throughout our region. Our comprehensive services include primary care, specialty care, behavioral health services, and care coordination to ensure our members receive holistic, integrated healthcare. Our collaborative approach fosters a supportive environment where every team member plays a vital role in our mission to provide accessible, high-quality healthcare services. From preventative care to managing chronic conditions, we're dedicated to empowering healthier lives and building a stronger, healthier community together.

In Short
? Manages day-to-day business area activities, provides leadership, coaching and training to team members, sets clear goals and expectations and manages performance as needed.
? Creates a positive work environment that fosters teamwork, empowerment, accountability, and superior customer service.
? Identifies trends, determines root causes, and takes action to resolve issues and initiate necessary process and procedural changes to improve internal and external customer satisfaction.
? Ensures all departmental and clinical reports and necessary reviews are completed in a timely manner.
? Maintains accountability for achieving targeted results and communicates regularly with organization leadership regarding workloads, issues, projects, monitoring of team performance and staffing needs.
? Leads special projects and/or represents the department on corporate projects that require independent, sound decision making and broad based understanding of effects on the department as a whole.
? Responsible for the application and compliance with all regulations, standards or other regulatory requirements applicable to departmental operations. Formulates corrective action plans to address any areas of non-compliance.
? Must maintain current knowledge in applicable clinical areas, standards and certifications (where required) and keep abreast of trends related to the health insurance industry.
? Facilitates meetings and conducts formal presentations for staff and/or cross functional or customer groups as needed.
? Assures turnaround times are met for clinical and non-clinical staff.
? Assist with deliverable projects with stringent state timelines as needed.
? Perform other duties and support deliverables as assigned by the organization to help drive our Vision, fulfill our Mission, and abide by our Organization?s Values.
Requirements
? RN/LPN/LVN with valid compact license is required.
? 3 years previous full time direct clinical nursing experience or 3 years in the health insurance industry in utilization management, managing health conditions, understanding medical criteria, medical guidelines, medical policy, and NCQA and DOI, Medicaid regulations.
? Demonstrated leadership skills (i.e. training, mentoring, coaching or assisting peers with issue resolution) or previous experience in a leadership role is required.
? Knowledge of Windows and Microsoft Office required, proficiency in Excel is preferred.
Benefits
? Equal opportunity employer that embraces individuals from all backgrounds.
? Prohibits discrimination and harassment of any kind.
? Ensures all employment decisions are based on qualifications, merit, and the needs of the business.

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