Utilization Review Nurse

Umpqua Health•Roseburg, OR

3d•Remote

About The Position

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.

Requirements

Licensure: Active, unrestricted Registered Nurse (RN), BSN (Bachelor of Science in Nursing, MSN (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.
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.

Nice To Haves

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.

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.