Qualified Clinical Reviewer & Program Coordinator (Medical Review Coordinator)

State of Oregon • Salem, OR

8d • $7,347 - $11,152 • Hybrid

About The Position

The Provider Clinical Support Services unit within the Oregon Health Authority's Medicaid Division supports Oregon Health Plan (OHP) Fee-for-Service (FFS) utilization management by ensuring members receive clinically appropriate, medically necessary, and policy-compliant health care services. The unit provides clinical expertise for prior authorization reviews, claims determinations, Medical Management Committee reviews, provider consultation, administrative hearings, and Oregon Administrative Rule (OAR) development. The team works closely with health care providers, Coordinated Care Organizations (CCOs), and internal agency partners to promote equitable access to medically necessary services while supporting high-quality clinical decision-making across the Medicaid program.

The Qualified Clinical Reviewer & Program Coordinator serves as a clinical authority responsible for reviewing complex medical documentation, interpreting clinical policy, and making evidence-based determinations that directly impact Oregon Health Plan members' access to care. In this position, you will conduct prior authorization and claims reviews, provide consultation to providers and agency staff, support the Medical Management Committee, serve as an expert witness during administrative hearings, and contribute to policy development, quality improvement, and program oversight. You will also monitor clinical trends, evaluate program effectiveness, collaborate with healthcare partners to improve continuity of care, and help ensure Medicaid services are delivered consistently, equitably, and in compliance with state and federal requirements.

It will be your responsibility and privilege to factor in the perspectives of diverse populations most harmed by social injustice and inequities including communities of color, immigrant groups, the disability and neurodivergent communities, veterans, older adults, individuals identifying as LGBTQIA+ and other communities that have been traditionally marginalized.

Requirements

• A current Registered Professional Nurse license issued by the Oregon State Board of Nursing at the time of appointment and maintained throughout employment
• Three years of nursing experience that includes review of medical records

Nice To Haves

• Knowledge of professional registered nursing practice, medical terminology, and national, statewide, and community standards of clinical care; experience applying clinical judgment to review complex medical documentation, verify medical necessity, and make independent clinical decisions related to prior authorization, claims review, utilization management, and quality assurance.
• Knowledge of health services delivery systems, particularly the Oregon Health Plan (Medicaid), including experience working with Fee-for-Service programs, Coordinated Care Organizations (CCOs), health care providers, hospitals, or other clinical partners.
• Knowledge of federal and state Medicaid regulations, Oregon Administrative Rules, Oregon Revised Statutes, and clinical policy; experience interpreting and applying laws, rules, regulations, and medical necessity criteria to ensure equitable, compliant, and consistent coverage authorization determinations.
• Strong oral and written communication skills across a variety of forums, including emails, reports, meetings, committees, and administrative hearings; experience preparing clear clinical documentation, reports, and determination letters and communicating complex medical and regulatory information in ways that are accessible, culturally responsive, and appropriate for audiences with different levels of understanding.
• Experience building collaborative relationships and effectively navigating challenging interactions with providers, members, leadership, and multidisciplinary partners while gathering information, resolving issues, and supporting continuity of care.
• Experience conducting clinical research, evaluating conflicting information, identifying root causes of issues, and synthesizing quantitative and qualitative information to support quality assurance, program improvement, and evidence-based decision making.
• Experience supporting policy development and implementation, utilization management, program monitoring, quality improvement, or healthcare operations through data analysis, policy interpretation, and collaboration across healthcare programs and partners.
• Evidence of ongoing development of personal cultural awareness and humility, and experience considering the perspectives of communities disproportionately impacted by health inequities when making clinical, policy, or program decisions.

Responsibilities

• Conduct prior authorization and claims reviews
• Provide consultation to providers and agency staff
• Support the Medical Management Committee
• Serve as an expert witness during administrative hearings
• Contribute to policy development, quality improvement, and program oversight
• Monitor clinical trends
• Evaluate program effectiveness
• Collaborate with healthcare partners to improve continuity of care
• Help ensure Medicaid services are delivered consistently, equitably, and in compliance with state and federal requirements

Benefits

• Excellent, low-cost medical, vision, and dental coverage for you and your family.
• Optional benefits like life insurance, disability coverage, deferred compensation, and FSA options for health and childcare.
• Generous paid time off: 11 holidays, 3 personal days, monthly sick leave, and vacation accrual starting at 8 hours/month.
• Potential eligibility for the Public Service Loan Forgiveness Program.
• Retirement security through Public Employees Retirement System (PERS)/Oregon Public Service Retirement Plan (OPSRP).
• Training and development opportunities to grow your career with the State of Oregon.

What This Job Offers

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