Utilization Review Coordinator Lead

Your Impact:

• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and internal and external guidelines. Leads also provide oversight, monitoring and training of these processes.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines. Leads also provide oversight, monitoring and training of these processes.
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures. Leads also provide oversight, monitoring and training of these processes.
• Conducts prior authorization and HRS flex reviews to determine medical necessity and appropriateness of services and financial responsibility. Leads also provide oversight, monitoring and training of these processes.
• Processes requests within required timelines. Leads also provide oversight, monitoring and training of these processes.
• Refers appropriate prior authorization and HRS flex requests to Medical Directors. Leads also provide oversight, monitoring and training of these processes.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs. Leads also provide oversight, monitoring and training of these processes.
• Collaborates with multidisciplinary teams to work with the care coordinators to ensure member receive integrated care coordination as needed. Leads also provide oversight, monitoring and training of these processes.
• Adheres to Umpqua Health policies and procedures and State, Federal and local regulations. Leads also provide oversight, monitoring and training of these processes.
• Advanced knowledge of the Oregon Administrative Rules (OAR) governing the Oregon Health Plan as well as all applicable Medicare guidelines. Referring to OHP/ Medicare websites as needed. This includes the understanding of the policies and procedures that apply to the Appeal and Grievance process and the Member’s Rights and responsibilities as stated by the Division of Medical Assistance Program (DMAP) as well as CMS.
• Ability to demonstrate an advanced proficiency of benefits for OHP/Medicare required.
• Work together with the Third-Party Recovery (TPR) department regarding any member with the potential for additional insurance coverage as well as reporting any case that may reach stop loss.
• Work with Customer Care department regarding eligibility issues including when a member has a change in address or moved out of area.
• Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost-effective care delivery.
• Responsible to ensure that treatment delivered is appropriately utilized and meets the member's needs in the least restrictive, least intrusive manner possible.
• Conduct high level audits and other investigatory activities to identify and rectify process improvement opportunities.
• Maintain understanding and participate in the discharge planning associated with inpatient/residential prior authorization reviews to ensure treatment plans and transitions of care are successful for members transferring to higher or lower levels of care within an allotted timeframe.
• Leadership skills required. Provide mentorship for staff and act as a role model. Oversight and monitoring of training and onboarding new and cross departmental staff.
• Leads high level projects (i.e., develop criteria tools, maintain regulations and documentation, Regulation Validation, gather and maintain resources, etc.).
• Ensures all resources are up to date and available to staff as needed for job performance (i.e., Updated PLHS, Fee Schedules (DMAP/CMS), Criteria's, etc.)
• Conducts interviews, makes hiring decisions and leads new-hire onboarding.
• Staff coaching and performance management as needed.
• Work collaboratively with leadership and staff to ensure efficient, system wide processes are in place.
• Develop and maintain department policies as assigned by Leadership.
• Oversee the daily activities of team.
• Ensure staff have huddles/meetings 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.
• Assign extra duties to staff when needed to fulfill needs of department.
• Perform basic time management duties (PTO requests, leave, timecards, etc.).
• Create and update workflows and operating procedures as needed.
• 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.

Your Credentials:

• Current RN, LPN, RT, LCSW, LPC, LMFT, Licensed Psychologist or equivalent license with 5+ years’ experience with varied medical and/or behavioral health exposure and capability. CACD I and higher for Behavioral Health position(s).
• 5+ years' experience in medical field and/or managed care/utilization related field. Experience includes acute care, case management, including cases that require rehabilitation, home health, behavioral health and hospice treatment.
• Managed care experience.
• Advanced knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits. Able to effectively communicate technical changes and onboard/train new staff.
• Advanced experience in quality improvement initiatives and population health management.
• Advanced PC navigational, MS Office (Word, Excel, Outlook), data entry, and internet research skills. This includes managing data within Excel reports through pivot tables, sorting, filtering, and managing big data. In addition, creating PowerPoint presentations, Visio workflows and documentation management.
• Proficiency with basic office equipment skills such as computer keyboarding, web-based phone queues and systems, cloud-based document storage, etc.
• Ability to type at least 45 wpm with a high degree of accuracy.
• Advanced proficiency data analytics skills; able to determine data fields, parameters, and run ad hoc reporting with little direction.
• Experience following established medical/clinical guidelines. Leads also provide oversight, monitoring and training of these processes.
• No suspension/exclusion/debarment from participation in federal health care programs (e.g., Medicare/Medicaid)