Qualified Clinical Reviewer, Program Coordinator

Jobtailor; Salem (OR); On-site; USD 85,000 - 110,000; Full time

Job summary

Jobtailor in Oregon seeks a Registered Nurse to review complex medical documentation, determine medical necessity, and authorize care under the Oregon Health Plan. You will apply clinical policy and collaborate with providers to ensure access and compliance with state and federal Medicaid rules.

You will support policy development, quality improvement, and program oversight, prepare determination letters, and communicate results in an accessible, culturally responsive manner to diverse

Qualifications

• Current RN license issued by the Oregon State Board of Nursing.
• Three years nursing experience including medical records review.
• Knowledge of professional registered nursing practice, medical terminology, and clinical care standards.
• Experience reviewing complex medical documentation, verifying medical necessity, and making clinical decisions related to prior authorization, claims review, utilization management, and quality assurance.
• Knowledge of Medicaid regulations and Oregon Administrative Rules, Oregon Revised Statutes, clinical policy, and medical necessity criteria.
• Strong oral and written communication skills.

Responsibilities

• Conduct prior authorization and claims reviews.
• Review complex medical documentation and interpret clinical policy.
• Make evidence-based determinations affecting Oregon Health Plan members' access to care.
• Provide consultation to health care providers and agency staff.
• Support the Medical Management Committee.
• Serve as an expert witness during administrative hearings.
• Contribute to policy development, quality improvement, and program oversight.
• Monitor clinical trends and evaluate program effectiveness.
• Collaborate with health care partners to improve continuity of care.
• Help ensure Medicaid services are delivered consistently, equitably, and in compliance with state and federal requirements.
• Consider perspectives of communities disproportionately affected by social injustice and health inequities.

Skills

Prior authorization

Claims review

Clinical policy

Communication

Cultural competence

Regulatory knowledge

Education

RN licensure

Job description

• Conduct prior authorization and claims reviews
• Review complex medical documentation and interpret clinical policy
• Make evidence-based determinations affecting Oregon Health Plan members' access to care
• Provide consultation to health care providers and agency staff
• Support the Medical Management Committee
• Serve as an expert witness during administrative hearings
• Contribute to policy development, quality improvement, and program oversight
• Monitor clinical trends and evaluate program effectiveness
• Collaborate with health care partners to improve continuity of care
• Help ensure Medicaid services are delivered consistently, equitably, and in compliance with state and federal requirements
• Consider perspectives of communities disproportionately affected by social injustice and health inequities

Requirements

• Current Registered Professional Nurse license issued by the Oregon State Board of Nursing at the time of appointment and maintained throughout employment
• Three years of nursing experience that includes review of medical records
• Knowledge of professional registered nursing practice, medical terminology, and clinical care standards
• Experience reviewing complex medical documentation, verifying medical necessity, and making clinical decisions related to prior authorization, claims review, utilization management, and quality assurance
• Knowledge of health services delivery systems, particularly Oregon Health Plan Medicaid and Fee-for-Service programs
• Knowledge of Coordinated Care Organizations, health care providers, hospitals, or other clinical partners
• Knowledge of federal and state Medicaid regulations, Oregon Administrative Rules, Oregon Revised Statutes, clinical policy, and medical necessity criteria
• Strong oral and written communication skills
• Experience preparing clinical documentation, reports, determination letters, and communicating medical and regulatory information accessibly and culturally responsively
• Experience building collaborative relationships and navigating challenging interactions with providers, members, leadership, and multidisciplinary partners
• Experience conducting clinical research, evaluating conflicting information, identifying root causes, and synthesizing quantitative and qualitative information
• Experience supporting policy development, utilization management, program monitoring, quality improvement, or healthcare operations
• Evidence of ongoing cultural awareness and humility
• Must pass criminal records and driving records checks meeting OHA criteria
• Must be authorized to work in the United States; position does not provide visa sponsorship

Core Competencies

Demonstrates expertise in prior authorization, claims review, and clinical policy interpretation, with a strong focus on Medicaid services and compliance with state and federal regulations. Proven ability to build collaborative relationships and effectively communicate complex medical information to diverse stakeholders.

Certifications & Qualifications

• Registered Professional Nurse License