Job Description

Umpqua Health is recruiting a  Utilization Review Coordinator to support our commitment to delivering timely, appropriate, and high-quality care for our members.  In this role, you’ll be responsible for evaluating authorization requests, coordinating with providers, and applying clinical standards to ensure members receive appropriate and timely care. You’ll use a combination of clinical judgment, regulatory knowledge, and system navigation skills to manage utilization reviews across medical, behavioral health, and substance use treatment services.  This position plays a vital role in supporting our members, particularly those with complex care needs, by applying evidence-based practices, adhering to regulatory standards, and collaborating across departments to ensure high-quality outcomes. Your Impact: Review clinical documentation for prospective, concurrent, and retrospective authorization requests to determine medical necessity and appropriateness of services. Apply Oregon Health Plan guidelines, InterQual criteria, ASAM standards, Medicare regulations, and internal policies to evaluate service authorizations and determine benefit coverage. Document clinical decision-making clearly and accurately in alignment with state and federal requirements, internal policies, and audit standards. Identify members who may benefit from case management or care coordination and make appropriate referrals to internal teams. Support transitions of care for members being discharged from inpatient, residential, or out-of-network facilities to ensure continuity and avoid service gaps. Partner with providers and vendor partners to facilitate care planning, authorization clarification, and non-contracted rate discussions when needed. Track and report key utilization trends, and contribute to process improvements that enhance service delivery and compliance. Participate in departmental initiatives such as audits, performance reviews, committee meetings, and regulatory reporting activities. Serve as a clinical resource to internal teams, supporting education, mentorship, and collaboration across health plan functions. Perform other duties as assigned to support Umpqua Health’s Vision, Mission, and Organizational Values. Your Credentials: Current, active licensure in one of the following: registered nurse (RN), licensed practical nurse (LPN), respiratory therapist (RT), licensed clinical social worker (LCSW), licensed professional counselor (LPC), licensed marriage and family therapist (LMFT), licensed psychologist, or equivalent. Certified Alcohol and Drug Counselor (CADC) I or higher required for behavioral health-focused roles, or the ability to obtain certification within the first 12 months of employment. Minimum of three (3) years of clinical experience in medical, behavioral health, or integrated healthcare settings, including direct support for individuals with complex needs. Exceptional written and verbal communication skills with the ability to present complex clinical information clearly and professionally to both clinical and non-clinical audiences. Technologically fluent and able to navigate complex data systems, health management platforms, and electronic medical record systems; proficient in Microsoft Office and virtual communication tools. Ability to independently manage a dynamic caseload with accountability for timeliness, accuracy, and compliance in all documentation and review activities. Demonstrated success working in high-accountability environments with shifting priorities, regulatory deadlines, and cross-functional collaboration. Must be in good standing with all applicable regulatory boards and not suspended, excluded, or debarred from participation in federal healthcare programs such as Medicare or Medicaid. About Umpqua Health 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. Umpqua Health serves Douglas County, Oregon, where we prioritize personalized care and innovative solutions to meet the diverse needs of our members. 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. Join us in making a difference at Umpqua Health. 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.

Job Tags

Full time, Local area, Remote job, Shift work,

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