Utilization Review Coordinator-Remote PST

The Role :

The Utilization Review Coordinator (URC) is a remote position that performs clinical reviews for Umpqua Health Alliance (UHA) to determine the medical necessity of requested services based on applicable Medicaid / Medicare policies and criteria. The utilization review coordinator will adhere to regulatory compliance requirements, department quality metrics and provide exceptional customer service to all internal and external customers.

Your Impact :

• Uphold high standards of data accuracyand documentation, ensuring all decisions are properly recorded in accordancewith regulatory requirements.
• Support the organizations mission byproviding exceptional customer service to all stakeholders, both internal andexternal.
• Monitor trends in utilization patternsand identify opportunities for process improvement or cost savings.
• Participate in internal audits andquality improvement initiatives to enhance review processes and ensureregulatory compliance.
• Provide education and guidance toproviders and staff regarding prior authorization processes and medicalnecessity criteria.
• Utilize healthcare technology and data systems effectively to manage caseloads and support efficient workflow processes.
• Review and assess medical service requests to determine medical necessity based on evidence-based clinical guidelines and Medicaid / Medicare criteria.
• Ensure timely processing of prior authorization and HRS Flex requests, referring cases to Medical Director when necessary.
• Evaluate the appropriateness of requested treatments, verifying member eligibility and benefits coverage.
• Communicate professionally with providers and members to request additional information when needed, ensuring clarity and efficiency in all interactions.
• Collaborate with care coordinators and multidisciplinary teams to support integrated, patient-centered care.
• Make referrals to other clinical programs to ensure members receive comprehensive services that address their individual needs.
• Maintain compliance with state, federal, and UHA regulations and guidelines, contributing to continuous quality improvement initiatives.
• Perform other duties and support deliverables as assignedby the organization to help drive our Vision, fulfill our Mission, and abide byour Organizations Values.

Your Credentials :

Salary : $80,000 - $85,000