Utilization Management Manager in McMinnville, Oregon - #73660 | VanderHouwen

Description

Job Id: 73660

Utilization Management Manager
Our client is seeking a Utilization Management Manager to lead the day-to-day operations of a Utilization Management program supporting Medicaid members and ensuring high-quality, timely, and compliant healthcare decisions. This role will oversee a team of UM professionals, partner closely with clinical and operational leaders, and use data and process improvement strategies to strengthen program effectiveness. The ideal candidate brings strong Oregon Medicaid expertise, proven UM leadership experience, and a thorough understanding of Medicaid managed care and regulatory requirements.

This role is fully remote. Applicants must reside in Oregon, Washington, Arizona, Florida, Idaho, Kentucky, Maine, North Carolina, Oklahoma, Pennsylvania, Tennessee, Texas, or Virginia.

Utilization Management Manager Responsibilities

• Lead the day-to-day operations of the Utilization Management program, including oversight of staff, workflows, work queues, reviews, and program deliverables.
• Ensure UM activities, determinations, documentation, and communications align with applicable Oregon Medicaid requirements, contractual obligations, and organizational policies.
• Supervise, coach, and develop the UM team, providing clear expectations, ongoing feedback, training, and support to promote consistent and accurate work.
• Partner with medical and nursing leadership on medical necessity reviews, peer-to-peer activities, appeals, complex cases, and other clinical review functions.
• Monitor program performance, productivity, quality, and compliance metrics, preparing reports and analysis for leadership and other stakeholders.
• Identify opportunities to improve UM processes, resolve operational barriers, and lead cross-functional initiatives that enhance efficiency, quality, and member outcomes.
• Collaborate with Care Management, Compliance, Provider Relations, and other internal teams, as well as external healthcare partners, to address UM-related issues and support continuity of care.
• Oversee the development, maintenance, and implementation of UM policies, procedures, screening tools, educational materials, and related resources.
• Ensure required regulatory, contractual, and operational reporting is completed accurately and within established timelines.
• Monitor UM activities for quality, compliance, and risk concerns and escalate issues appropriately through clinical and organizational leadership.
• Support regulatory audits, quality initiatives, and organizational efforts designed to improve healthcare outcomes and member experience.
• Promote a collaborative, accountable, and inclusive team environment while effectively managing priorities within a dynamic healthcare setting.

Utilization Management Manager Qualifications

• 2+ years of experience leading a Utilization Management program.
• 2+ years of experience working with Oregon Medicaid.
• Experience with a Coordinated Care Organization (CCO), Medicaid Managed Care organization, or similar healthcare environment.
• 3+ years of supervisory or team leadership experience, preferably within healthcare, nursing, or utilization management.
• Bachelor’s degree in Nursing, Healthcare Administration, Behavioral Health, or another related healthcare field; equivalent combinations of education and experience may be considered.
• Strong knowledge of Medicaid and Medicare utilization management requirements, applicable regulatory standards, and healthcare quality expectations.
• Demonstrated understanding of medical necessity review, utilization criteria, appeals, denial management, and related clinical review processes.
• Experience using data, performance metrics, and reporting to evaluate program effectiveness and drive process improvements.
• Strong critical thinking, problem-solving, conflict resolution, and decision-making skills.
• Excellent written and verbal communication skills, with the ability to work effectively with clinical professionals, operational teams, providers, and external partners.
• Highly organized and able to manage multiple priorities, deadlines, and regulatory requirements while maintaining accuracy and attention to detail.
• Experience with physical and behavioral health integration is preferred.
• Master’s degree in Nursing or another healthcare-related field is preferred.
• Professional certifications such as CCM, ACM, CPHQ, or nursing case management certification are preferred.

Salary: $111K-$142K/year + Bonus. (DOE)

Benefits
Benefits are available to eligible full-time employees and include coverage for medical, dental, vision, life insurance, short and long term disability, and matching 401k.

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