Providence Health & Services Clinical Manager, Facility Based Utilization Review in Beaverton, Oregon
Providence St. Joseph Health is calling a Manager, Utilization Management Inpatient, Concurrent Review to our location in Beaverton, OR.
Providence Health Plan is looking for an enthusiastic, innovative leader to manage our Concurrent Review Utilization Management team. This role oversees facility based authorization processes and procedures including discharge planning and care transitions across multiple settings to ensure our members have a seamless health care experience. We are looking for a leader with expertise in utilization management, mentoring a diverse team, and meeting compliance and regulatory requirements of governing agencies such as NCQA, CMS and OHA. If you are looking for a rewarding leadership position with opportunity to grow within a comprehensive health care organization this role may be for you.
In this position you will have the following responsibilities:
Manage the operations and support team within Health Care Services including the Call Center, Utilization Management or Care Management intake & review functions which includes but is not limited to prior authorization, concurrent review (CCR), Claims, skilled nursing facility (SNF) Review and care management services.
Provide oversight and direction for systems and tools used internally by staff and externally by provider partners to assist in Medical or Care Management operations.
Achieve organizational performance standards for Call Center activities, prior authorization, CCR review, SNF review, Claims Audit, Care Management and other areas as deemed appropriate.
Prepare and manages budget for applicable area(s).
Manage coordination of all work, quality improvement activities, projects, objectives and staffing of the department by working with other Managers and Supervisors within Health Care Services.
Evaluate performance and initiates personnel actions such as hiring, merit increases, probationary and periodic reviews, promotions, work plans and disciplinary actions.
Collaborate across Health Care Services departments to assure cross-functional workflow integration in all dependent areas.
Establish and sustain open and transparent communication across divisions and departments within Health Care Services as well as PHP.
Ensure responsible areas are compliant with all service level agreements, regulatory requirements, contractual requirements and accreditation bodies and that policies & procedures accurately reflect the current guidance and regulations.
Establish and maintain quantitative and qualitative performance standards and workload metrics for caregivers in addition to tracking and providing timely reports for caregivers and leadership as needed.
Work with peers on new products, benefit changes, and new lines of business in order to establish service team coverage as well as the necessary system changes.
Routinely review and re-engineer operations through continuous quality improvement as needed to meet demands.
Health Care Services Expert, ability to deliver affordable healthcare by applying stratification and impactful interventions; combining medical management, care management, community partners, delivery systems, and regulatory requirements to meet the needs of our population.
Required qualifications for this position include:
Graduate from an accredited school of nursing or graduate from an accredited equivalent clinical program.
Bachelor’s degree in Nursing or other clinical field.
Formal education or training in supervision, management, or leadership.
3 years documented direct management or supervisory experience in a clinical or managed care setting.
5 years of clinical experience.
2 years utilization, quality or care management experience in an insurance or managed care setting.
Demonstrated experience in program planning, development and evaluation.
Currently licensed as a registered nurse in good standing in Oregon or current equivalent clinical license.
Preferred qualifications for this position include:
Master’s degree in Nursing, or related field.
Certification in case management, utilization management or quality improvement.
Project management, Six Sigma, Lean, Change Acceleration Process (CAP) experience or certification.
Experience with HEDIS, CAHPS, Medicare 5-Star Rating, NCQA and/or URAC accreditation.
About Providence in Oregon
As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.
The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple,
"Providence will provide the best care and service to every person, every time."
Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Nurse Lead/Supervisor/Manager
Req ID: 331080