Utilization Review Specialist

Umpqua Health; Roseburg (OR); Remote; USD 60,000 - 80,000; Full time

Job summary

A community-driven health organization is seeking a Utilization Review Specialist I to support prior authorization processes. This remote, full-time position requires a high school diploma and proficiency in MS Office along with strong organizational skills. The ideal candidate has over one year of experience in the medical field and can manage multiple priorities while adhering to regulations.

Qualifications

• Proficient in typing at least 45 words per minute accurately.
• Knowledge of Oregon health regulations and medical terminology.
• Over 1 year of experience in medical or managed care fields.

Responsibilities

• Provide support for Utilization Review and Care Coordination.
• Manage documentation from multiple sources daily.
• Research and respond to customer requests regarding prior authorizations.

Skills

PC navigation

MS Office proficiency

Data entry

Internet research

Bilingual capabilities

Organizational skills

Communication skills

Education

High school diploma or equivalent

Job description

Job Description

JOB TITLE

Utilization Review Specialist I

REPORTS TO

Utilization Review Manager

STATUS

Full-Time, Non-Exempt

WAGE RANGE

Grade 13 (2024)

DEPARTMENT

Utilization Review

WORK LOCATION

Remote

POSITION PURPOSE

The Utilization Review Specialist I provides support to Umpqua Health Alliance (UHA) for the intake, processing of, and finalization of all prior authorizations received by Medical Management in compliance with regulatory requirements.

ESSENTIAL JOB RESPONSIBILITIES

1. Provide support for Utilization Review and Care Coordination related to prior authorization processes.
2. Manage receipt of documentation from multiple sources daily, including appeals, grievances, and prior authorizations.
3. Identify incoming documentation requests and redistribute to appropriate staff for processing.
4. Track and sort prior authorization requests and supporting information using current systems.
5. Support timely notification of prior authorization determinations.
6. Coordinate with other Specialists for daily department telephone coverage.
7. Research and respond to internal and external customer requests regarding prior authorizations; refer members and providers as needed.
8. Support the Appeals & Grievances Coordinator as needed.
9. Participate in training, audits, and meetings.
10. Maintain understanding of relevant regulations and procedures.
11. Monitor daily reports for compliance.
12. Adhere to internal policies, procedures, Code of Conduct, and applicable regulations.
13. Perform other duties as assigned.

CHALLENGES

• Working with diverse personalities and maintaining fair communication.
• Satisfying the needs of a fast-paced, challenging environment.
• Managing shifting priorities and coordinating resources effectively.

QUALIFICATIONS

Minimum Qualifications

• High school diploma or equivalent.
• Proficient in PC navigation, MS Office, data entry, and internet research.
• Ability to type at least 45 wpm accurately.
• No suspension or exclusion from federal health care programs.

Preferred Qualifications

• Experience considering impacts on diverse communities.
• Experience working with diverse teams and communication styles.
• Bilingual capabilities a plus.
• Over 1 year of experience in medical or managed care fields.
• Knowledge of Oregon health regulations and medical terminology.
• Strong organizational and communication skills.
• Ability to work independently and remotely, managing multiple priorities.

PHYSICAL DEMANDS

Standing, sitting, walking, bending, and lifting up to 25 pounds.

EQUAL EMPLOYMENT OPPORTUNITY

Umpqua Health is committed to diversity and prohibits discrimination based on protected characteristics. We base employment decisions on qualifications, merit, and business needs.

JOB DESCRIPTION ACKNOWLEDGEMENT

I have reviewed the attached job description and understand my responsibilities. I will contact HR if accommodations are needed. This description is not exhaustive and may be modified as needed.

About Umpqua Health

Umpqua Health is a community-driven CCO committed to improving health and well-being through comprehensive, coordinated care. We serve Douglas County, Oregon, providing primary, specialty, behavioral health, and care coordination services. We value diversity, fairness, and community engagement.