Utilization Review Coord (WA/OR residency -Hybrid)

Kaiser Permanente Northwest; Portland (OR); On-site; USD 50,000 - 63,000; Full time

Job summary

Kaiser Permanente Northwest in Portland, OR seeks a dedicated Utilization Review professional to evaluate medical necessity and appropriate care across the continuum. You will communicate with physicians, staff, and members about denials and coverage, while supporting education and compliance initiatives.

Strong attention to detail, critical thinking, and collaboration are essential as you assess trends and contribute to cost-effective care under standard policies.

Qualifications

• Minimum qualification: Bachelor's degree or, alternatively, at least three years of medical benefits administration experience in a managed health care setting.
• Candidates should demonstrate strong attention to detail, communication, and problem-solving abilities.

Responsibilities

• Performs utilization reviews of medical records and treatment plans to evaluate necessity, appropriateness, and efficiency.
• Engages with physicians, managers, staff, members and caregivers regarding medical necessity and benefit denials.
• Supports utilization management education and compliance initiatives through staying current with regulations.
• Identifies utilization trends and opportunities to improve workflows and outcomes.
• Collaborates with team to address deficiencies and ensure compliant, cost-effective care.
• Follows policies to ensure timely, accurate reviews under guidance.

Skills

Attention to detail

Communication

Critical thinking

Decision making

Problem solving

Teamwork

Learning agility

Adaptability

Integrity

Diversity & inclusion support

Education

Bachelor's degree in Health Care Administration or related field

Job description

Conducts reviews of medical records and treatment plans to evaluate and consult on necessity, appropriateness, and efficiency of health care services, under guidance. Communicates with physicians, managers, staff, members and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care, independently. Observes and identifies utilization trends and learns about addressing deficiencies in utilization review workflow/processes to ensure compliant and cost-effective care. Supports education and compliance initiatives by remaining up-to-date on the relevant regulations and guidelines, and participating in and providing feedback on education and training programs for staff and physicians to promote best practices in utilization management.

Essential Responsibilities

• Pursues effective relationships with others by sharing resources, information, and knowledge with coworkers and members. Listens to, addresses, and seeks performance feedback. Pursues self-development; acknowledges strengths and weaknesses based on career goals and takes appropriate development action to leverage / improve them. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work. Assesses and responds to the needs of others to support a business outcome.
• Completes work assignments by applying up-to-date knowledge in subject area to meet deadlines; follows procedures and policies, and applies data and resources to support projects or initiatives with limited guidance and/or sponsorship. Collaborates with others to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports the completion of priorities, deadlines, and expectations. Identifies and speaks up for ways to address improvement opportunities.
• Supports high‑quality consultation by: communicating with physicians, managers, staff, members, and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care, independently; and leveraging working knowledge to ensure the correct and consistent application, interpretation, and utilization of member health care benefits, cost of care options, and coverage by members and physicians.
• Supports education and compliance initiatives by: remaining up-to-date and discussing with the team the relevant state and federal regulations, guidelines, criteria, and documentation requirements that affect utilization management; and participating and providing feedback on education and training programs for staff and physicians at the local level to promote best practices in utilization management.
• Assists in quality improvement efforts by: observing and identifying utilization patterns, trends, and opportunities for improvement; learning about utilization review workflows/processes including corrective action plans and standard work, and identifying deficiencies in workflows; and learning and actively adhering to utilization policies, procedures, and guidelines to ensure compliant and cost‑effective care.
• Performs utilization reviews by: following standard policies and procedures when conducting reviews of medical records and treatment plans to evaluate the medical necessity, appropriateness, and efficiency of requested health care services, under guidance; and assessing the ongoing need for services, identifying potential issues/delays, and recommending appropriate actions for standard member cases.

Knowledge, Skills and Abilities: (Core)

• Ambiguity/Uncertainty Management
• Attention to Detail
• Business Knowledge
• Communication
• Critical Thinking
• Cross-Group Collaboration
• Decision Making
• Dependability
• Diversity, Equity, and Inclusion Support
• Drives Results
• Facilitation Skills
• Health Care Industry
• Influencing Others
• Integrity
• Learning Agility
• Organizational Savvy
• Problem Solving
• Short- and Long-term Learning & Recall
• Teamwork
• Topic-Specific Communication

Knowledge, Skills and Abilities: (Functional)

• Acts with Compassion
• Confidentiality
• Consulting
• Evidence-Based Medicine Principles
• Quality Assurance and Effectiveness
• Relationship Building
• Written Communication

Minimum Qualifications

• Bachelors degree in Health Care Administration, Business, Nursing, or directly related field OR minimum three (3) years of experience in medical benefits administration in a managed or health care setting or a directly related field.

Preferred Qualifications

• N/A

Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.

Primary Location: Oregon,Portland,Kaiser Permanente Building

Scheduled Weekly Hours: 40

Shift: Day

Workdays: Mon, Tue, Wed, Thu, Fri

Working Hours Start: 08:00 AM

Working Hours End: 05:00 PM

Job Schedule: Full-time

Job Type: Standard

Worker Location: Flexible

Employee Status: Regular

Employee Group/Union Affiliation: NUE-NW-02|NUE|Non Union Employee

Job Level: Individual Contributor

Department: Kaiser Permanente Building - OSM SVC ADMIN-DME - 1008

Pay Range: $35.72 - $46.16 / hour

Kaiser Permanente strives to offer a market competitive total rewards package and is committed to pay equity and transparency. The posted pay range is based on possible base salaries for the role and does not reflect the full value of our total rewards package. Actual base pay determined at offer will be based on labor market data, internal alignment, and a candidate's years of relevant work experience, education, certifications, skills, and geographic location.

Travel: No

Work Setting: Flexible

Worker location must align with Kaiser Permanente's Authorized States policy.