Utilization Review Specialist

Umpqua Health • Roseburg, OR

1d • Hybrid

About The Position

At Umpqua Health, we are a community-driven Coordinated Care Organization (CCO) dedicated to improving the health and well-being of individuals and families throughout Douglas County, Oregon. We provide integrated, whole-person care through primary care, specialty care, behavioral health services, and care coordination, ensuring high-quality, personalized care. The Utilization Review Specialist supports the Umpqua Health Alliance (UHA) by managing the intake, processing, and finalization of all prior authorizations received by Medical Management, ensuring compliance with regulatory requirements.

Requirements

• High school diploma or equivalent.
• Proficient computer skills, including Microsoft Office Suite (Word, Excel, Outlook, Teams), data entry, and internet research.
• Experience using standard office equipment and systems, including keyboarding, web-based phone systems, and cloud-based document storage.
• Ability to type a minimum of 45 words per minute with a high degree of accuracy.
• Strong attention to detail.
• No suspension, exclusion, or debarment from participation in federal healthcare programs (e.g., Medicare/Medicaid).

Nice To Haves

• 1+ years of experience in the medical field, managed care, medical coding, claims processing, or related field
• Knowledge of medical terminology, procedure codes, and diagnosis codes.
• Familiarity with Oregon Health Plan (OHP) and Coordinated Care Organizations (CCO), including applicable regulations (e.g., OAR, ORS, CFR, CMS, DMAP).
• Experience working in diverse teams and with varying communication styles.
• Experience considering the impact of work on multiple communities, including communities of color.
• Bilingual or translation skills are preferred.
• Strong organizational skills with the ability to manage multiple priorities, meet deadlines, and maintain attention to detail in a fast-paced environment.
• Ability to exercise sound judgment, maintain strict confidentiality, and work both independently and collaboratively.
• Effective interpersonal, written, and verbal communication skills, with strong customer service orientation.
• Demonstrated critical thinking and time management skills to prioritize workload and meet turnaround expectations.
• Self-motivated with the ability to follow policies, procedures, and workflows in a remote environment.
• Ability to meet productivity standards and maintain accuracy and timeliness under pressure.
• Flexible and adaptable in a dynamic work environment.
• Ability to work on a standard schedule, Monday through Friday, 8:00 AM – 5:00 PM PST.
• Willingness to learn new skills and take on additional responsibilities as needed

Responsibilities

• Provide support for the Utilization Review as related to the prior authorization process.
• Manage the receipt of prior authorization requests and documentation through multiple sources.
• Identify incoming requests, assess completeness, and redistribute to appropriate individual(s) for processing
• Communicate with healthcare providers to obtain additional information, clarify documentation, and resolve issues
• Track and sort prior authorization requests and support information using current systems and processes.
• Support the timely notification of prior authorization determinations.
• Coordinate with other Utilization Review Specialists for daily management of department telephone coverage with individual login and availability.
• Research and respond to requests from internal and external customers regarding prior authorizations. Refer members and providers to other appropriate staff as necessary.
• Provide support to the Utilization Review Coordinator as needed.
• Participate in department training, audits, and meetings as needed.
• Maintain a solid understanding of regulations and procedures.
• Create and monitor daily reports for timeline compliance.
• Comply with organization’s internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations.
• 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: High school or GED
• Number of Employees: 11-50 employees