Utilization Review Nurse Team Lead

Umpqua Health • Roseburg, OR

5d • Hybrid

About The Position

The Utilization Management Nurse Team Lead partners with the Utilization Review Nurse Manager to support and oversee the team in evaluating clinical service requests for medical necessity, cost-effectiveness, and evidence-based care. This role provides guidance in applying professional nursing judgment across prior authorization, care coordination, and transitions of care. The Team Lead ensures compliance with Oregon Health Plan (OHP), Medicare, and all applicable regulatory requirements, while supporting timely access to appropriate services. This position also promotes collaboration with interdisciplinary teams and community providers to enhance care integration, quality outcomes, and continuous improvement in utilization management processes.

Requirements

• Active, unrestricted Registered Nurse (RN) license in the state of Oregon or a Nurse Licensure Compact state
• Graduate of an accredited nursing program
• Minimum of two (2) years of utilization review experience within a managed care organization
• Experience applying clinical judgment to assess medical necessity using evidence-based guidelines (e.g., InterQual)
• Working knowledge of Oregon Health Plan (OHP)/CCO requirements and applicable regulatory standards (e.g., NCQA, CMS)
• Proficiency in Microsoft Office and electronic health record (EHR) or utilization management systems
• Strong written and verbal communication skills with the ability to collaborate across interdisciplinary teams
• Ability to manage multiple priorities, analyze complex cases, and maintain attention to detail
• Adherence to all federal healthcare program requirements; no history of suspension, exclusion, or debarment from Medicare or Medicaid
• Valid driver’s license and current auto insurance required if job duties included travel

Nice To Haves

• Bachelor's or master's degree in nursing (BSN or MSN)
• Experience with quality improvement, audits, and reporting
• Knowledge of contractual benefits and alternative coverage options
• Experience working with diverse populations and applying equity in decision-making
• Bilingual proficiency, including the ability to communicate and translate in another language

Responsibilities

• Perform clinical assessments of 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 support timely, cost-effective, and high-quality care.
• Identify and escalate complex cases to Medical Directors; obtain and evaluate additional clinical documentation as needed.
• Collaborate with care coordinators, discharge planners, and interdisciplinary teams to support care integration and safe transitions across settings.
• Participate in discharge planning for members transitioning across levels of care, ensuring continuity and support for physical and behavioral health needs.
• Ensure access to appropriate services in the least restrictive setting while maintaining quality and continuity of care.
• Maintain knowledge of Oregon Health Plan (OHP), Medicare, and applicable regulatory requirements; ensure compliance with organizational and regulatory standards.
• Serve as a clinical liaison with internal departments to resolve eligibility, coordination of benefits, and related issues.
• Support quality improvement efforts by participating in audits, identifying trends, and recommending process enhancements.
• Provide training, mentorship, and ongoing support to staff on clinical workflows and utilization management protocols.
• Develop and maintain departmental resources, tools, and training materials to support accurate and consistent determinations.
• Partner with leadership to support policy and procedure development and serve as a clinical resource for complex cases.
• Perform other duties as assigned.

Benefits

• Salary is dependent on skills, experience, and education
• Generous benefits package including vacation PTO, sick leave, federal holidays, and birthday leave
• Medical, dental, and vision insurance
• 401(k) with company match (fully vested immediately)
• Company-sponsored life insurance and additional benefits
• Fitness reimbursement program
• Tuition reimbursement and more

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree