Utilization Review Specialist
HYBRID, must be able to travel to 3031 NE STEPHENS ST. ROSEBURG, OR 97470
EMPLOYMENT TYPE- Full-Time, Exempt
POSITION PURPOSE
The Utilization Review Specialist supports Umpqua Health Alliance by coordinating the intake, review, processing, and completion of prior authorization requests within Medical Management. This role is responsible for ensuring accurate and timely handling of authorizations, maintaining compliance with regulatory and organizational requirements, supporting communication with providers and members, and assisting with workflow coordination to promote efficient utilization management operations.
ESSENTIAL JOB RESPONSIBILITIES
Support Utilization Review activities related to the prior authorization process.
Manage intake, tracking, and routing of prior authorization requests and supporting documentation.
Review requests for completeness and ensure appropriate routing for processing.
Communicate with healthcare providers to obtain additional information and resolve documentation issues.
Track prior authorization requests using established systems to ensure timely processing.
Support timely notification of prior authorization determinations.
Coordinate daily workflow and telephone coverage with team members.
Respond to internal and external inquiries regarding prior authorizations and route as appropriate.
Monitor and report on turnaround times to ensure compliance with requirements.
Maintain knowledge of applicable regulations, policies, and procedures.
Comply with organizational policies and applicable to federal, state, and local regulations.
Strong organizational skills with the ability to stay organized and productive in a remote, independent work environment
Proactive communication with internal and external stakeholders
Consistent ability to meet Oregon Health Plan (OHA) timeline and turnaround requirements
Ability to manage shifting priorities in a fast-paced environment
Ability to coordinate tasks and resources to meet operational goals and objectives
- 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)
1+ years of experience in healthcare, managed care, medical coding, claims processing, or a 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 (OAR, ORS, CFR, CMS, DMAP)
Strong organizational skills with the ability to manage multiple priorities in a fast-paced environment
Ability to meet deadlines while maintaining accuracy and attention to detail
Strong communication and customer service skills (written, verbal, and interpersonal)
Ability to work independently and collaboratively with sound judgment and confidentiality
Strong critical thinking and time management skills
Self-motivated with ability to follow policies, procedures, and workflows in a remote environment
Flexible and adaptable in a changing work environment
Willingness to learn and take on additional responsibilities as needed
Ability to work a standard schedule: Monday–Friday, 8:00 AM–5:00 PM PST
Experience working in diverse teams and with varied communication styles
Experience considering the impact of work on diverse communities, including communities of color
Bilingual or translation skills preferred
SCHEDULE
Monday through Friday - 8:00am - 5:00pm; standard business hours with flexibility to meet service timelines.
SALARY
Wage Band : $41,600- $47,000
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
Inclusive Culture
We foster a respectful, inclusive environment where employees feel valued, supported, and empowered.
Growth & Development
We support ongoing learning through mentorship, clear career pathways, and professional development opportunities.
Work/Life Balance
We promote flexibility and well-being so employees can thrive both professionally and personally.
Skills Required
- 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).
- 1+ years of experience in healthcare, managed care, medical coding, claims processing, or a 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 (OAR, ORS, CFR, CMS, DMAP).
- Strong organizational skills with the ability to manage multiple priorities in a fast-paced environment.
- Ability to meet deadlines while maintaining accuracy and attention to detail.
- Strong communication and customer service skills (written, verbal, and interpersonal).
- Ability to work independently and collaboratively with sound judgment and confidentiality.
- Strong critical thinking and time management skills.
- Self-motivated with ability to follow policies, procedures, and workflows in a remote environment.
- Flexible and adaptable in a changing work environment.
- Willingness to learn and take on additional responsibilities as needed.
- Ability to work a standard schedule: Monday-Friday, 8:00 AM-5:00 PM PST.
- Experience working in diverse teams and with varied communication styles; experience considering impact on diverse communities.
- Bilingual or translation skills.
What We Do
Umpqua Health is a mission-driven, community-focused healthcare organization and Coordinated Care Organization (CCO) based in Roseburg, Oregon. It coordinates care for Oregon Health Plan members across Douglas County, providing integrated primary, behavioral, dental, and urgent care through its Umpqua Health Alliance and Newton Creek Clinic while focusing on whole-person care, care coordination, and community health programs.
