Yamhill Community Care

Title: Social Needs Project Specialist - Hybrid Nonprofit Role Location: McMinnville OR US Job Description: Primary Work Location: Remote (Oregon Headquarters)This position is Local Hybrid with flexibility to work both remotely and/or in-person at YCCO's office in McMinnville and open only to candidates residing in the local McMinnville, OR Area. Department: Health Plan Operations FLSA Status: Exempt Division: Community Health Physical Strength: Light (L) Reports To: Community Health Systems & Tribal Relations Manager Location: Local Hybrid Supervisory role: No Occasional Weekend Work: Yes About Us: Yamhill Community Care is a nonprofit coordinated care organization dedicated to managing the healthcare for Medicaid members, covered under the Oregon Health Plan, in Yamhill County, as well as parts of Washington and Polk Counties. Our mission is to improve the quality of life of the communities we serve by coordinating effective care. Beyond healthcare, we also provide an Early Learning Hub, supporting families and children with essential resources and programs for early childhood development. Together, we're building a unified healthy community that celebrates physical, mental, emotional, spiritual, and social well-being. Learn more about Yamhill Community Care: click here Summary The Social Needs Project Specialist expands, maintains, and monitors capacity for social needs services and supports eligible Yamhill Community Care (YCCO) members, by working with various vendors, community-based organizations, and providers of targeted resources and services offering nutrition, housing, and other social supports. This position also works extensively with internal teams including Care Management (CM) and Utilization Management (UM). This position requires extensive knowledge of resources within the community and an understanding of barriers that impact individuals and families in YCCO communities, which may prevent them from accessing and/or obtaining the resources they need for stability. Essential Duties - Develops strategies and policies for partnership with community and provider organizations to create a social needs provider network that can meet the social needs of all eligible members. - Builds and maintains a consistent and reliable network of providers. - Manages strong relationships with stakeholders in order to support coordination with internal CM program and staff and addresses barriers concerning benefit delivery. - Manages collaborative projects within and across teams that may include, but is not limited to, other program Specialists, Community Health Workers (CHW), CM Case Managers, Nurse Case Managers, Community Providers, Health Supervisor, Traditional Health Worker Liaison. - Designs and presents training materials and process documents offering guidance around social needs benefits, programs, and services. Job Duties Community Resource Development - Interprets Oregon Health Authority (OHA) contract and state and federal regulations, incentive metric requirements, Health Equity Plan, and other plan-related documents to maintain compliance with social needs benefit and service delivery requirements. - Develops strategic engagement and relations plan for YCCO’s partnership with community-based organizations and local and state service providers and vendors. - Develops and maintains policies and procedures regarding the provision of health-related services benefit and services and the social needs provider network. - Manages the compilation and inventory of resources available throughout the YCCO region and surrounding counties to meet the health-related social needs of members, including food, housing, and climate supports. - Develops and maintains cross-agency partnerships and relationships that will support YCCO’s social needs. Leads Community Information Exchange implementation and process improvement activities. - Delivers OHA and internally required reports and documentation related to Heath Related Social Needs services resources and services. Provider Network Management - Recruits, supports, and provides technical assistance for contracted social needs providers to maintain reporting and provider agreement compliance. - Supports and maintains processes related to social needs requests through Community Information Exchange and Prior Authorization pathways. - Manages conflicts, barriers, issues and/or concerns between vendors / service providers and members or CM staff. - Develops new and support existing resources within the community to build and maintain YCCO’s social needs screening and support network. - Serves as a liaison, in coordination with Provider Relations, between internal CCO (Community Care Organization) staff and external partners to facilitate collaboration and maintain positive community relations. - Provides support with any partnerships between YCCO and Tribal or Urban Indian Health Program entities, including contract oversight and issue resolution as appropriate. Social Needs Project Leadership - Engages with OHA around related social needs and benefit meetings, work sessions, and activities to ensure new information is incorporated in program processes. - Develops and maintains social needs capacity assessment at least annually, with analysis of available local social needs organizations and capacity to meet regional member needs. - Serves as main liaison for Community Information Exchange implementation internally and with community partners. - Directs social needs screening implementation practices with community partners, social needs providers, and support with social needs integration and reporting efforts community-wide. - Represent YCCO at OHA and state meetings as appropriate. - Leads collaborative work within and across teams that may include, but is not limited to, other Project Specialists, CHW’s, CM Case Managers, Nurse Case Managers, Community Providers, Health Services Supervisor, Traditional Health Worker Liaison. - Develops workflows, Standard Operating Procedures (SOP), and process improvement plans to guide social needs benefit and health related services review, authorization, service delivery, and monitoring. - Acts as an individual contributor to other CCO initiatives, Quality Assurance and Compliance activities, and assists with data reviews and processes. - Champions health equity and YCCO efforts to redistribute power and resources; recognizes, reconciles, and rectifies historical and contemporary injustices within the YCCO healthcare and social service systems. Social Needs Focus Areas Climate Devices, Nutrition & Housing Services - Maintains a current understanding of local resources and services. - Develops and maintains positive relationships and working agreements with CCO, local vendors, and services providers. - Works with contracts department to create Memorandums of Understanding (MOU) or agreements to establish services and devices (if necessary). - Works with Finance to determine inventory and supply demand in case of climate emergency. - Serves as a liaison, and/or supports CCO liaison efforts, between vendors, service providers and members during conflicts / issues with a goal of preventing the loss of partnerships and/or contracts. - Identifies gaps in resources and services and identify solutions to address these gaps. - Prepares social needs related reports. - Regularly attends YCCO’s Community Advisory Council (CAC) meetings to coordinate social needs screening and program processes with Children’s Health Insurance Program (CHIP) related programs and interventions. Essential Department & Organizational Functions - Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members. - Manages projects end-to-end related to social needs initiatives and improvement activities. - Participates in the preparation and submission of regulatory and contract required deliverables. - Works closely with other YCCO departments, including Compliance to assist with audits; including the External Quality Review (EQR), as needed. - Proposes and implements process improvements. - Meets deadlines for completion of assigned responsibilities and projects. - Maintains agreed upon work schedule with punctual, regular, and predictable attendance. - Attends in person Annual Company Conference in Oregon; typically held in the fourth week of September. - Demonstrates cooperation and teamwork using a professional and respectful demeanor. - Provides cross-training on specific job responsibilities. - Meets identified goals that contribute to departmental goals. - Respectfully takes direction from Supervisor. - Performs other duties as assigned. Knowledge, Skills, & Abilities - Knowledge of social determinant of health and their relationship to a person’s overall well-being. - Ability to prepare clear and concise reports. - Ability to build relationships and network with individuals at all levels, both internal and external to the organization. - Ability to work in an environment with diverse individuals, open-minded and non-judgmental including working with those who may hold different values / experiences, such as cultural needs, language, economic status, life experience, etc. - Ability to learn and apply policies, regulations, requirements, and rules. - Exhibits strong organizational and record keeping skills including the ability to handle multiple priorities and demands in a dynamic work environment. - Excellent organizational skills including ability to handle multiple priorities and demands simultaneously in a dynamic work environment while maintaining high attention to detail and accuracy. - Familiarity with project management concepts and principles. - Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a Matrix (cross-department) or shared resources across departments work model with a spirit of cooperation. - Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook. - Ability to communicate both professionally and effectively in all forms of communication. - Ability to work in an environment with diverse individuals and groups. - Ability to remain flexible, positive, and adaptable. - Ability to work across the YCCO region and to work remotely, as needed. Supervisory Responsibilities - This position has no supervisory responsibility Qualifications Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties. Education & Experience Required: - Bachelor’s degree in Community Health, Communications, Public Health, Social Work, Public Administration, or related field, - Two (2) years of experience in Health Insurance, Utilization Management, Program Coordination, Planning, and Development of Community Resources. OR: - Any combination of education and experience that would qualify candidate for the position. Preferred: - Project Management or Administrative Management experience. - Bilingual Skills (English / Spanish, Skills Pay available). - Systems experience with Medicaid population. - Experience working with affordable housing programs. Certificates, Licenses and/or Registrations - This position does not require any certificates, licenses, or registrations. Physical Demands & Work Environment The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this position. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit, stand, walk, use hands and fingers, handle or feel, and reach with hands and arms. The employee is occasionally required to climb or balance, stoop, kneel, crouch or crawl. The employee may occasionally need to lift and/or move up to 25 pounds. This position operates in a professional office environment and requires frequent use of standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Specific vision abilities required by this job include close vision, color vision, distance vision, depth perception, and ability to adjust focus. The noise level in the work environment is usually moderate. This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.

Title: Utilization Management Manager – Remote Nonprofit Role Location: REMOTE - USA $111,000 ‒ $142,500 Annually Job Description: Primary Work Location: Remote (Oregon Headquarters). This position is 100% remote and open only to candidates residing in states where the organization is authorized to do business. Authorized Remote States: Oregon, Arizona, Florida, Idaho, Kentucky, Maine, North Carolina, Oklahoma, Pennsylvania, Tennessee, Texas, Virginia, Washington. Department: Health Plan Operations FLSA Status: Exempt (Salaried) Division: Utilization Management Physical Strength: Light (L) Reports To: Nursing Director - RN Work Location Type: Hybrid / 100% Remote Supervisory Role: Yes Occasional Weekend Work: No About Us: Yamhill Community Care is a nonprofit coordinated care organization dedicated to managing the healthcare for Medicaid members, covered under the Oregon Health Plan, in Yamhill County, as well as parts of Washington and Polk Counties. Our mission is to improve the quality of life of the communities we serve by coordinating effective care. Beyond healthcare, we also provide an Early Learning Hub, supporting families and children with essential resources and programs for early childhood development. Together, we're building a unified healthy community that celebrates physical, mental, emotional, spiritual, and social well-being. Learn more about Yamhill Community Care: click here Summary This position is responsible for the successful oversight and management of the Utilization Management (UM) team and associated activities and deliverables. Working collaboratively across Yamhill Community Care (YCCO) teams as well as with external partners and the community. This position will manage the day-to-day operations and direct supervision of UM staff. This UM Manager monitors the effectiveness / outcomes of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed. The UM Manager will manage a team that supports the triple aim and positive outcomes for YCCO members. Essential Duties - Works collaboratively with the Chief of Health Plan Operations, Nursing Director–RN to ensure the UM program meets Oregon Administrative Rules (OARs), contractual obligations, and organizational policies. - Oversees and supports UM processes to ensure effective and compliant UM reviews that meet State and Federal rules and regulations. - Collaborates with the YCCO Chief Medical Officer (CMO) and/or Associate Medical Director to facilitate peer-to-peer review, developing and interpreting medical necessity policies and their application, and other review activities. - Effectively and efficiently manages a diverse workforce in a fast-paced, dynamic regulatory environment. - Leads process improvement initiatives within the UM program, working with a variety of departments and multi-disciplinary staff. Job Duties - Ensures integrated UM program activities meet OARs and contractual obligations. Includes, but is not limited, to the following: - Develops and oversees UM policies and processes working in collaboration with the Nursing Director - RN, the CMO, and the Associate Medical Director to ensure that UM activities, documentation, and reporting supports quality, timely, and compliant deliverables. - Collaborates and coordinates across providers and healthcare settings to ensure optimal quality outcomes. - Ensures support for the YCCO CMO and/or Associate Medical Director in the provision of peer-to-peer and other review activities. - Seeks consultation with CMO, the Associate Medical Director and/or Nursing Director–RN, as needed, to support quality of care. - Refers UM issues to the Nursing Director–RN and/or CMO, Associate Medical Director or the CMO in a timely manner and monitors the issue until it is resolved. - Collaborates with the Care Management team to support members’ successful transitions between levels of care. - Ensures member and other communications and notices are composed in a manner consistent with regulatory standards. - Ensures effective management of work queues and other UM deliverables. - Ensures performance of all necessary UM-related reviews within required timelines or earlier as directed. - Collaborates with internal and external entities to support the successful resolution of medical necessity and other reviews. - Provides consultation regarding UM to physicians and other colleagues within the Yamhill Health system working in collaboration with the CMO, Nursing Director–RN and Provider Relations. - Ensures that UM staff are consistent in conducting medical necessity review/appeals to ensure appropriateness of care. - Documents UM, quality, and risk concerns and refers to appropriate departments as applicable for follow-up. Supervision of Utilization Management Team - Communicates with team members daily/weekly/monthly, as appropriate, to support individual staff and the team’s ability to meet program deliverables and outcomes. - Monitors and works with staff to be compliant with deliverables, required timelines, and other performance elements. - Supports onboarding, training, and education across teams. - Supports team’s adherence to Policies and Procedures set forth by the organization and State regulations/contract. - Serves as a resource person for UM staff and others to ensure consistent and accurate UM determinations. - Ensures staff respond to all requests appropriately, accurately, and timely according to policies. - Participates in the orientation of new department staff specific to UM. - Develops and provides individualized UM-related education as needed. Oversight of Utilization Management Program Deliverables - Participates in the preparation and submission of regulatory and contract required deliverables. - Ensures that UM documentation is entered in a clear, organized, and timely manner that is compliant with OAR / ORS and contractual requirement. - Develops and maintains UM policies and procedures. - Ensures ongoing compliance monitoring of UM functions. - Completes assignments, monthly statistics, and all other required reporting. - Monitors UM for quality and risk concerns. - Refer to appropriate departments as applicable. - Facilitates the necessary updates of UM related screening tools and resources, creation of training tools, and providing training to UM staff. - Prepares succinct, written UM related documentation as directed by the Nursing Director-RN. - Participates in, and/or leads, assigned Committee and UM activities. - Ensures documentation of activities are entered in a clear, concise, organized, and timely manner. Participate in Performance Improvement Activities - Uses data to drive decisions and plans / implements performance improvement strategies related to UM activities. - Creates reports, displaying data and providing narrative analysis, to a variety of audiences. - Identifies and facilitates resolution of system process issues impeding UM functions. - Identifies and resolves delays and obstacles as appropriate. - Leads and participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff. - Participates in development, implementation, teaching, evaluation, and revision of departmental standards related to UM. Management & Leadership - Champions the organization's mission, vision, and goals. - Inspires and motivates employees, aligns teams with company objectives, and helps maintain a positive company culture. - Communicates clear expectations, goals, and standards to all department staff to ensure alignment and accountability. - Ensures staff have the necessary training, equipment, tools, and resources to perform their roles effectively by working with Human Resources. - Analyzes and monitors staff productivity and work quality, reorganizing and distributing work assignments needed for optimal performance. - Provides consistent, fair, and supportive supervision of all assigned department staff. - Partners with Supervisor and Human Resources to manage human resource functions such as interviewing, hiring, onboarding, training employees, conflict resolution, and performance management. - Meets YCCO’s employee coaching standards through consistent 1:1 (one on one) and performance coaching meetings with all department assigned staff. - Provides department with ongoing understanding of the transformation, strategic plans and operational direction of YCCO. - Provides staff with the training, tools, and resources necessary to carry out assigned work. - Analyzes staffing needs and reorganizes work and assignments, as needed. - Supervises assigned unit staff in a consistent manner. - Evaluates unit employees’ performance both informally and formally and takes corrective action in collaboration with the Nursing Director–RN and Human Resources to address areas of opportunity. Essential Department & Organizational Functions - Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members. - Participates in the preparation and submission of regulatory and contract required deliverables. - Works closely with other YCCO departments, including Compliance to assist with audits; including the External Quality Review (EQR), as needed. - Supports the organization’s quality improvement goals, including contributing to quality incentive programs and supporting measurable progress on quality metrics that advance the health and well-being of the communities we serve. - Proposes and implements process improvements. - Meets deadlines for completion of assigned responsibilities and projects. - Maintains agreed upon work schedule with punctual, regular, and predictable attendance. - Attends in person Annual Company Conference in Oregon; typically held in the fourth week of September. - Demonstrates cooperation and teamwork using a professional and respectful demeanor. - Provides cross-training on specific job responsibilities. - Meets identified goals that contribute to departmental goals. - Respectfully takes direction from Supervisor. - Other duties as assigned. Knowledge, Skills, & Abilities - Demonstrate a working knowledge of regulatory and survey standards (Medicare, Medicaid, Joint Commission, and NCQA). - Demonstrate a working knowledge of disease, including mental illness and addiction, and age specific impact. - Demonstrate a working knowledge of approved status determination criteria and apply consistently according to interrater reliability techniques. - Demonstrates a working knowledge of rapid-cycle process improvement. - Apply advanced critical thinking and conflict resolution skills using creative approaches. - Ability to utilize negotiation skills, which effectively promote constructive solutions. - Work collaboratively and professionally across YCCO teams as well as with external partners and the community. - Excellent interpersonal communication, problem-solving, and conflict resolution skills. - Knowledgeable in areas of: Medicare and Medicaid UM regulations, McKesson InterQual, Medicare. Inpatient Only List, HERC (Health Evidence Review Commission) Guidelines, RAC (Recover Audit Contractors), QIO (Quality Improvement Organizations), MAC (Medical Administrative Contractors), and Denial Management. - Demonstrate positive and professional written, verbal, and nonverbal communication skills. - Excellent organizational skills including ability to handle multiple priorities and demands simultaneously in a dynamic work environment while maintaining high attention to detail and accuracy. - Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a Matrix (cross-department) or shared resources across departments work model with a spirit of cooperation. - Excellent computer skills, including Microsoft Windows, Word, Excel, Outlook and other software tools for analysis and presentation of UM related data. - Ability to communicate both professionally and effectively in all forms of communication. - Ability to work in an environment with diverse individuals and groups. - Ability to remain flexible, positive, and adaptable. Ability to work across the YCCO region and to work remotely, as needed. Supervisory Responsibilities Directly supervises employees in the Utilization Management program. Carries out supervisory responsibilities in accordance with the organization’s policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems. Qualifications Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential duties. Education & Experience Required: - Bachelor’s degree in Nursing or other Healthcare related field, such as Behavioral Health, Healthcare Administration, - Three (3+) years of experience supervising or leading teams, - Two (2+) years of Utilization Management experience. OR: - Any combination of education and experience that would qualify candidate for the position. Preferred: - Master’s degree in Nursing or other Healthcare related field, - Five (5) years of relevant clinical nursing or healthcare related experience, - Experienced in physical and behavioral health integration, - Experience with Coordinated Care Organization (CCO) / Medicaid Managed Care, - Three (3+) years of experience with Utilizations Management, - Equivalent combination of education and experience will be considered. Certificates, Licenses, and/or Registrations Preferred: - ACM (Accredited Case Manager) through AMCA (American Case Management Association), - CCM (Certified Case Manager) CCMC (Commission for Case Manager Certification), - Board certification in Nursing Case Management (RN-BC) through ANCC (American Nurses Credentialing Center), - CPHQ (Certified Professional in Health Care Quality) through NAHQ (National Association of Health Care Quality). Physical Demands & Work Environment The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this position. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this position. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential duties. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit, stand, walk, use hands and fingers, handle or feel, and reach with hands and arms. The employee is occasionally required to climb or balance, stoop, kneel, crouch or crawl. The employee may occasionally need to lift and/or move up to 25 pounds. This position operates in a professional office environment and requires frequent use of standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Specific vision abilities required by this job include close vision, color vision, distance vision, depth perception, and ability to adjust focus. The noise level in the work environment is usually moderate. This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.