Utilization Review Specialist

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

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.