Job Description| JOB TITLE | Utilization Review Nurse | REPORTS TO | Utilization Review Manager |
| STATUS | FT Exempt | WAGE RANGE | Grade 20 (2024) |
| DEPARTMENT | Utilization Management | WORK LOCATION | Remote (occasional travel as required) |
| POSITION PURPOSE |
| The Utilization Management Nurse is responsible for evaluating clinical service requests to ensure medically necessary cost-effective and evidence-based care for members. This role applies professional nursing judgment to conduct prior authorization reviews facilitate care coordination and support transitions across care settings. The nurse ensures compliance with Oregon Health Plan (OHP) Medicare and applicable regulatory guidelines while a assuring member access to appropriate services. Through collaboration with interdisciplinary teams and community providers the Utilization Management Nurse promotes integrated high-quality care and contributes to continuous improvement in utilization management processes. |
| ESSENTIAL JOB RESPONSIBILITIES |
- Performing clinical assessments of various medical service requests to determine medical necessity appropriateness and alignment with evidence-based guidelines and benefit coverage.
- Conduct prior authorization and HRS flex reviews applying nursing judgment to ensure timely cost-effective and high-quality care delivery.
- Identify and escalate complex or non-standard cases to Medical Directors; request and evaluate additional clinical documentation as needed.
- Collaborate with care coordinators discharge planners and interdisciplinary teams to support integrated care and safe transitions across care settings.
- Maintain up-to-date knowledge of Oregon Health Plan (OHP) Medicare and applicable regulatory frameworks (OAR ORS CFR CMS DMAP).
- Serve as a clinical liaison with internal departments (e.g. Third-Party Recovery Customer Care) to resolve eligibility coordination of benefits and stop-loss concerns.
- Ensuring access to appropriate services in the least restrictive setting while supporting continuity and quality of care.
- Participate in discharge planning for members transitioning from acute long-term or residential care to community-based services ensuring holistic support for physical and behavioral health needs.
- Conduct departmental audits and contribute to quality improvement initiatives by identifying trends and recommending process enhancements.
- Provide training and mentorship to new and cross-functional staff on clinical workflows and UM protocols.
- Build and maintain collaborative relationships with community providers and service organizations to support member care plans.
- Ensure compliance with organizational policies clinical standards and all applicable federal and state regulations.
- Conduct work independently and in collaboration with the Utilization Management (UM) team to ensure accurate and appropriate determinations.
- Perform other nursing-related duties as assigned.
|
| CHALLENGES |
- Working with a variety of personalities maintaining a consistent and fair communication style.
- Satisfying the needs of a fast paced and challenging company.
|
| QUALIFICATIONS |
Minimum Qualifications- Licensure: Active unrestricted Registered Nurse (RN) BSN (Bachelor of Science in NursingMSN (Master of Science in Nursing)license in the state of Oregon or a compact state.
- Education: Graduation from an accredited nursing program.
- Experience: Minimum of five (5) years of direct patient care experience in a clinical setting such as a medical office hospital or long-term care facility.
Core Competencies & Skills- Clinical Nursing Expertise: Deep understanding of medical terminology diagnoses procedures and care modalities. Experienced in interpreting clinical documentation and applying nursing knowledge to support utilization review and care decisions.
- Utilization Management: Proficient in InterQual criteria UM software and evidence-based guidelines. Skilled in reviewing requests for medical services and ensuring appropriate use of resources.
- Regulatory Compliance: Strong working knowledge of NCQA standards Oregon Health Plan (OHP) and Coordinated Care Organization (CCO) regulations including OAR ORS CFR CMS DMAP and the Prioritized List of Health Services.
- Medical Coding & Insurance: Familiar with ICD and CPT codes health insurance processes and state-mandated benefits.
- Technology & Documentation: Proficient in Microsoft Office (Word Excel Outlook) EHR systems and managed care platforms. Accurate typing at 45 WPM.
- Communication & Collaboration: Excellent interpersonal written and verbal communication skills. Builds strong relationships with providers community services and internal teams.
- Organization & Problem Solving: Highly organized and detail-oriented. Capable of managing multiple priorities analyzing complex situations and developing effective solutions.
- Ethical Standards: Maintains compliance with federal healthcare program requirements. No suspension exclusion or debarment from Medicare/Medicaid.
Preferred Qualifications- Two (2) years of utilization review or case management experience in a managed care organization or commercial insurance.
- Oregon residency and Oregon nursing license.
- Proficient in electronic systems for data entry and retrieval.
- Strong critical thinking time management and organizational skills to meet goals and deadlines.
- Demonstrated ability to work independently and collaboratively in fast-paced environments.
- Committed to continuous learning and expanding responsibilities.
- Knowledgeable in contractual benefits and alternative coverage options.
- Maintains patient confidentiality and secure health record practices.
- Current clinical certification and up-to-date knowledge base.
- Capable of conducting quality improvement audits and reporting findings.
- Effective in managing multiple priorities with attention to detail and accuracy.
- Experience working on diverse teams and considering equity impacts in decision-making.
- Bilingual capabilities or translation experience is a plus.
|
| PHYSICAL DEMANDS & WORK CONDITIONS |
- A typical office environment requires standing sitting walking bending and lifting up to 25 plus pounds.
- Ability to travel and drive to in-person meetings or be on-site as required.
- May be exposed to patient and environment conditions such as unpleasant sights smells and contagious diseases (clinic only).
|
| EQUAL EMPLOYMENT OPPORTUNITY |
| UH is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race color sex religion sexual orientation national origin disability genetic information pregnancy or any other protected characteristic as outlined by federal state or local laws. This policy applies to all employment practices within our organization including hiring recruiting promotion termination layoff recall leave of absence compensation benefits training and apprenticeship. UH makes hiring decisions based solely on qualifications merit and business needs at the time. For more information read through our EEO Policy. |
| JOB DESCRIPTION ACKNOWLEDGEMENT |
| I have reviewed the attached job description as outlined above and understand that I am responsible for all duties as outlined and other tasks as may be assigned. I understand that if Ineed accommodation to perform the essential functions of my job that I must contact my supervisor or Human Resources as soon as possible to begin an interactive process. |
|
| Note: This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully the incumbents will possess the skills aptitudes and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge skills or abilities. This document does not create an employment contract implied or otherwise other than an at will relationship. |
About Umpqua Health
At Umpqua Health were more than just a healthcare organization; were 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 were 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.
Required Experience:
Manager
Job DescriptionJOB TITLEUtilization Review NurseREPORTS TOUtilization Review ManagerSTATUSFT ExemptWAGE RANGEGrade 20 (2024)DEPARTMENTUtilization ManagementWORK LOCATIONRemote (occasional travel as required)POSITION PURPOSEThe Utilization Management Nurse is responsible for evaluating clinical servi...
Job Description| JOB TITLE | Utilization Review Nurse | REPORTS TO | Utilization Review Manager |
| STATUS | FT Exempt | WAGE RANGE | Grade 20 (2024) |
| DEPARTMENT | Utilization Management | WORK LOCATION | Remote (occasional travel as required) |
| POSITION PURPOSE |
| The Utilization Management Nurse is responsible for evaluating clinical service requests to ensure medically necessary cost-effective and evidence-based care for members. This role applies professional nursing judgment to conduct prior authorization reviews facilitate care coordination and support transitions across care settings. The nurse ensures compliance with Oregon Health Plan (OHP) Medicare and applicable regulatory guidelines while a assuring member access to appropriate services. Through collaboration with interdisciplinary teams and community providers the Utilization Management Nurse promotes integrated high-quality care and contributes to continuous improvement in utilization management processes. |
| ESSENTIAL JOB RESPONSIBILITIES |
- Performing clinical assessments of various medical service requests to determine medical necessity appropriateness and alignment with evidence-based guidelines and benefit coverage.
- Conduct prior authorization and HRS flex reviews applying nursing judgment to ensure timely cost-effective and high-quality care delivery.
- Identify and escalate complex or non-standard cases to Medical Directors; request and evaluate additional clinical documentation as needed.
- Collaborate with care coordinators discharge planners and interdisciplinary teams to support integrated care and safe transitions across care settings.
- Maintain up-to-date knowledge of Oregon Health Plan (OHP) Medicare and applicable regulatory frameworks (OAR ORS CFR CMS DMAP).
- Serve as a clinical liaison with internal departments (e.g. Third-Party Recovery Customer Care) to resolve eligibility coordination of benefits and stop-loss concerns.
- Ensuring access to appropriate services in the least restrictive setting while supporting continuity and quality of care.
- Participate in discharge planning for members transitioning from acute long-term or residential care to community-based services ensuring holistic support for physical and behavioral health needs.
- Conduct departmental audits and contribute to quality improvement initiatives by identifying trends and recommending process enhancements.
- Provide training and mentorship to new and cross-functional staff on clinical workflows and UM protocols.
- Build and maintain collaborative relationships with community providers and service organizations to support member care plans.
- Ensure compliance with organizational policies clinical standards and all applicable federal and state regulations.
- Conduct work independently and in collaboration with the Utilization Management (UM) team to ensure accurate and appropriate determinations.
- Perform other nursing-related duties as assigned.
|
| CHALLENGES |
- Working with a variety of personalities maintaining a consistent and fair communication style.
- Satisfying the needs of a fast paced and challenging company.
|
| QUALIFICATIONS |
Minimum Qualifications- Licensure: Active unrestricted Registered Nurse (RN) BSN (Bachelor of Science in NursingMSN (Master of Science in Nursing)license in the state of Oregon or a compact state.
- Education: Graduation from an accredited nursing program.
- Experience: Minimum of five (5) years of direct patient care experience in a clinical setting such as a medical office hospital or long-term care facility.
Core Competencies & Skills- Clinical Nursing Expertise: Deep understanding of medical terminology diagnoses procedures and care modalities. Experienced in interpreting clinical documentation and applying nursing knowledge to support utilization review and care decisions.
- Utilization Management: Proficient in InterQual criteria UM software and evidence-based guidelines. Skilled in reviewing requests for medical services and ensuring appropriate use of resources.
- Regulatory Compliance: Strong working knowledge of NCQA standards Oregon Health Plan (OHP) and Coordinated Care Organization (CCO) regulations including OAR ORS CFR CMS DMAP and the Prioritized List of Health Services.
- Medical Coding & Insurance: Familiar with ICD and CPT codes health insurance processes and state-mandated benefits.
- Technology & Documentation: Proficient in Microsoft Office (Word Excel Outlook) EHR systems and managed care platforms. Accurate typing at 45 WPM.
- Communication & Collaboration: Excellent interpersonal written and verbal communication skills. Builds strong relationships with providers community services and internal teams.
- Organization & Problem Solving: Highly organized and detail-oriented. Capable of managing multiple priorities analyzing complex situations and developing effective solutions.
- Ethical Standards: Maintains compliance with federal healthcare program requirements. No suspension exclusion or debarment from Medicare/Medicaid.
Preferred Qualifications- Two (2) years of utilization review or case management experience in a managed care organization or commercial insurance.
- Oregon residency and Oregon nursing license.
- Proficient in electronic systems for data entry and retrieval.
- Strong critical thinking time management and organizational skills to meet goals and deadlines.
- Demonstrated ability to work independently and collaboratively in fast-paced environments.
- Committed to continuous learning and expanding responsibilities.
- Knowledgeable in contractual benefits and alternative coverage options.
- Maintains patient confidentiality and secure health record practices.
- Current clinical certification and up-to-date knowledge base.
- Capable of conducting quality improvement audits and reporting findings.
- Effective in managing multiple priorities with attention to detail and accuracy.
- Experience working on diverse teams and considering equity impacts in decision-making.
- Bilingual capabilities or translation experience is a plus.
|
| PHYSICAL DEMANDS & WORK CONDITIONS |
- A typical office environment requires standing sitting walking bending and lifting up to 25 plus pounds.
- Ability to travel and drive to in-person meetings or be on-site as required.
- May be exposed to patient and environment conditions such as unpleasant sights smells and contagious diseases (clinic only).
|
| EQUAL EMPLOYMENT OPPORTUNITY |
| UH is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race color sex religion sexual orientation national origin disability genetic information pregnancy or any other protected characteristic as outlined by federal state or local laws. This policy applies to all employment practices within our organization including hiring recruiting promotion termination layoff recall leave of absence compensation benefits training and apprenticeship. UH makes hiring decisions based solely on qualifications merit and business needs at the time. For more information read through our EEO Policy. |
| JOB DESCRIPTION ACKNOWLEDGEMENT |
| I have reviewed the attached job description as outlined above and understand that I am responsible for all duties as outlined and other tasks as may be assigned. I understand that if Ineed accommodation to perform the essential functions of my job that I must contact my supervisor or Human Resources as soon as possible to begin an interactive process. |
|
| Note: This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully the incumbents will possess the skills aptitudes and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge skills or abilities. This document does not create an employment contract implied or otherwise other than an at will relationship. |
About Umpqua Health
At Umpqua Health were more than just a healthcare organization; were 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 were 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.
Required Experience:
Manager
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Not Disclosed
Posted on:
13 hours ago
Vacancies:
1 Vacancy
