Associate Utilization Review Specialist

Providence • Portland, OR

14h • $25 - $51 • Remote

About The Position

Associate Utilization Review Specialist - Remote Providence Health Plan is calling an Associate Utilization Review Specialist who will: Be responsible for all core functions in the Prior Authorization (PA) Department Coordinate and execute the review and research functions required to support the PA Department Investigate, review, and prepare all requests for prior authorization review for all lines of business (LOB) in multiple applications (Facets, CIM, CareAdvance, etc.) while using multiple resources to support the review (Medical Policies, KMS, Benefit Grids, Handbooks, etc.) Critically assess and prepare all cases for RN/MD review of coverage (medical necessity, eligibility, network status, regulatory) Uses appropriate resources and sound judgement to review and approve specific service requests based on deep understanding of medical service requested, CPT/HCPCS codes, and plan design. Authorizes select medical services Provide research, assessment, and proposed resolution of operational issues as they relate to coverage policy, correct coding (CPT/HCSPCS, Dx), regulations, and other coverage rules Take incoming phone calls from providers and members regarding operational plan functions with an ability to research and follow-up on unique prior authorization related requests and plan processes for all lines of business Responsible for ensuring service review requests and inquiries are complete and adjudicated to meet regulatory and compliance requirements, including timeliness Consult, or triage to, appropriate subject matter experts internally and across departments Work in a fast-paced environment with strict compliance and turn-around-times for all work metrics (prior authorization requests, customer service inquiries, provider resolutions, etc.) Providence Health Plan caregivers are not simply valued – they’re invaluable. Join our team at Providence Health Plan Partners and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. This position offers 100% remote work and is open to candidates residing in: Oregon Washington California

Requirements

• Bachelor's Degree in Health related field., Or Applicable 2 years work experience may be substituted for some education.
• 2 years experience in healthcare related field (or equivalent education)
• 1 year experience and proven track record of researching and resolving complex problems which required critical thinking
• 2 years experience in fast-paced working environment with a proven record of successful ability to quickly prioritize and resolve issues to meeting timeliness and quality metrics.
• 1 year experience in database management and spreadsheets.
• 6 months experience with telephony systems, call center phone volumes and multi-line communication systems.

Nice To Haves

• 3 years experience in healthcare related field (or equivalent education)

Responsibilities

• Be responsible for all core functions in the Prior Authorization (PA) Department
• Coordinate and execute the review and research functions required to support the PA Department
• Investigate, review, and prepare all requests for prior authorization review for all lines of business (LOB) in multiple applications (Facets, CIM, CareAdvance, etc.) while using multiple resources to support the review (Medical Policies, KMS, Benefit Grids, Handbooks, etc.)
• Critically assess and prepare all cases for RN/MD review of coverage (medical necessity, eligibility, network status, regulatory)
• Uses appropriate resources and sound judgement to review and approve specific service requests based on deep understanding of medical service requested, CPT/HCPCS codes, and plan design.
• Authorizes select medical services
• Provide research, assessment, and proposed resolution of operational issues as they relate to coverage policy, correct coding (CPT/HCSPCS, Dx), regulations, and other coverage rules
• Take incoming phone calls from providers and members regarding operational plan functions with an ability to research and follow-up on unique prior authorization related requests and plan processes for all lines of business
• Responsible for ensuring service review requests and inquiries are complete and adjudicated to meet regulatory and compliance requirements, including timeliness
• Consult, or triage to, appropriate subject matter experts internally and across departments
• Work in a fast-paced environment with strict compliance and turn-around-times for all work metrics (prior authorization requests, customer service inquiries, provider resolutions, etc.)

Benefits

• Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security.
• We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.
• Accepting a new position at another facility that is part of the Providence family of organizations may change your current benefits.
• Changes in benefits, including paid time-off, happen for various reasons.
• These reasons can include changes of Legal Employer, FTE, Union, location, time-off plan policies, availability of health and welfare benefit plan offerings, and other various reasons.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level