Utilization Review Coordinator

At Umpqua Health, we're more than just a healthcare organization; we're a community-driven Coordinated Care Organization (CCO) committed to improving the health and well-being of individuals and families throughout our region. Our comprehensive services include primary care, specialty care, behavioral health services, and care coordination to ensure our members receive holistic, integrated healthcare. Our collaborative approach fosters a supportive environment where every team member plays a vital role in our mission to provide accessible, high-quality healthcare services. From preventative care to managing chronic conditions, we're dedicated to empowering healthier lives and building a stronger, healthier community together.

Umpqua Health strongly encourages applications from candidates of color as well as veterans, aiming to foster a work environment that is linguistically and culturally diverse and inclusive. Please note that at this time, Umpqua Health does not offer visa sponsorship.

The Utilization Review Coordinator (URC) is a remote position that performs clinical reviews for Umpqua Health Alliance (UHA) to determine the medical necessity of requested services based on applicable Medicaid/Medicare policies and criteria. The utilization review coordinator will adhere to regulatory compliance requirements, department quality metrics and provide exceptional customer service to all internal and external customers. 

•  Always demonstrate the highest performance and behavior standards.  Share responsibility and expect others to be accountable. 
• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and internal and external guidelines. 
• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and internal and external guidelines. 
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines. 
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures. 
• Conducts prior authorization and HRS flex reviews to determine medical necessity and appropriateness of services and financial responsibility.  
• Processes requests within required timelines. 
• Refers appropriate prior authorization and HRS flex requests to Medical Directors. 
• Requests additional information from members or providers in consistent and efficient manner. 
• Makes appropriate referrals to other clinical programs. 
• Collaborates with multidisciplinary teams to work with the care coordinators to ensure member receive integrated care coordination as needed. 
• Adheres to Umpqua Health policies and procedures and State, Federal and local regulations. 
• Basic knowledge of the Oregon Administrative Rules (OAR) governing the Oregon Health Plan as well as all applicable Medicare guidelines. Referring to OHP/ Medicare websites as needed. This includes the understanding of the policies and procedures that apply to the Appeal and Grievance process and the Member’s Rights and responsibilities as stated by the Division of Medical Assistance Program (DMAP) as well as CMS. 
• Demonstrate an understanding and knowledge of benefits for OHP/Medicare. 
• Work together with the Third-Party Recovery (TPR) department regarding any member with the potential for additional insurance coverage as well as reporting any case that may reach stop loss. 
• Work with Customer Care department regarding eligibility issues including when a member has a change in address or moved out of area. 
• Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost-effective care delivery.  
• Responsible to ensure that treatment delivered is appropriately utilized and meets the member's needs in the least restrictive, least intrusive manner possible. 

• Preferred Qualifications: 
• Working knowledge of community services, providers, vendors, and facilities available to assist members.  
• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and internal and external guidelines. 
• Current RN, LPN, RT, LCSW, LPC, LMFT, Licensed Psychologist or equivalent license with 3+ years’ experience with varied medical and/or behavioral health exposure and capability. CACD I and higher for Behavioral Health position(s). 
• Proficient PC navigational, MS Office (Word, Excel, Outlook), data entry, and internet research skills. 
• Proficiency with basic office equipment skills such as computer keyboarding, web-based phone queues and systems, cloud-based document storage, etc.  
• Ability to type at least 45 wpm with a high degree of accuracy.  
• Advanced proficiency with critical thinking and time management skills to organize and prioritize workload according to goals and specified turnaround times.  
• High attention to detail. Advanced proficiency with critical thinking and time management skills to organize and prioritize workload according to goals and specified turnaround times. 
• No suspension/exclusion/debarment from participation in federal health care programs (e.g., Medicare/Medicaid) 
• Managed care experience. Proficient knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits.  
• Develop an understanding of the laws, regulations, policies, and evidence-based, clinical criteria governing Oregon Health Plan (OHP) and Coordinated Care Organizations (CCO). This includes but is not limited to: Oregon Administrative Rules (OAR), Code of Federal Regulations (CFR), Oregon State Legislature (ORS), Prioritized List of Health Services, Division of Medical Assistance Program (DMAP) and Centers for Medicare and Medicaid Services (CMS).  
• Basic interpersonal, written, and oral communication skills. 
• Ability to provide exemplary customer service to internal and external customers. 
• Establishes and maintains relationships with community services and providers.  
• Ability to work well in team setting, as well as independently, and be flexible and adapt to different dynamics in a fast-paced work environment.  
• Willingness to learn new skills and take on new responsibilities. 
• Ability to support organizational and program-specific mission and goals. 
• Ability to effectively collaborate with others and function as a part of a highly functioning team. 
• Ability to work effectively with a team, other departments, and exercise sound judgment in handling assigned tasks including maintenance of strict confidentiality. 

Umpqua Health is an equal opportunity employer that embraces individuals from all backgrounds. We prohibit discrimination and harassment of any kind, ensuring that all employment decisions are based on qualifications, merit, and the needs of the business. Our dedication to fairness and equality extends to all aspects of employment, including hiring, training, promotion, and compensation, without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other protected category under federal, state, or local law.