What are the responsibilities and job description for the Utilization Review Coordinator position at Umpqua Health Management LLC?
As a Utilization Review Coordinator with Umpqua Health Alliance (UHA), you’ll be at the forefront of ensuring high-quality care by determining the medical necessity of requested services using Medicaid/Medicare criteria. In this remote position, you’ll combine clinical expertise, exceptional customer service, and a commitment to compliance to make a tangible impact on healthcare outcomes.
Your Impact
- Champion Accuracy: Maintain meticulous documentation and data accuracy, ensuring all decisions comply with regulatory standards.
- Customer Service Excellence: Deliver outstanding support to both internal and external stakeholders, embodying UHA’s mission.
- Optimize Processes: Monitor utilization trends, identifying opportunities for improvement and cost savings.
- Enhance Quality: Participate in audits and quality improvement initiatives to refine review processes and ensure compliance.
- Educate and Support: Provide clear guidance to providers and staff on prior authorization processes and medical necessity criteria.
- Leverage Technology: Manage caseloads efficiently through effective use of healthcare technology and data systems.
Day-to-Day Responsibilities
- Review and assess medical service requests, ensuring they align with evidence-based clinical guidelines and Medicaid/Medicare policies.
- Process prior authorization and HRS Flex requests promptly, referring cases to the Medical Director when necessary.
- Evaluate treatment appropriateness by verifying member eligibility and benefits coverage.
- Communicate clearly and professionally with providers and members to request additional information when needed.
- Collaborate with care coordinators and multidisciplinary teams to support integrated, patient-centered care.
- Refer members to other clinical programs to provide comprehensive, individualized services.
- Perform additional duties as assigned to support the organization's vision, mission, and values.
What You Bring to the Table
- Credentials: Registered Nurse (RN), LPN, LVN, or equivalent clinical certification preferred.
- Experience: Prior background in utilization review, case management, or healthcare administration within managed care, Medicaid, or Medicare.
- Knowledge: Strong understanding of prior authorization processes, medical necessity criteria, and healthcare regulations.
- Skills: Excellent analytical and critical thinking abilities to interpret clinical data and apply evidence-based guidelines.
- Adaptability: Comfort working independently in a remote environment while meeting performance goals.
- Tech Savvy: Proficiency in healthcare software, with exceptional attention to detail and documentation accuracy.
Why Join Us? At Umpqua Health Alliance, you’ll play a critical role in shaping the future of healthcare. We believe in empowering our team with flexibility, innovation, and the opportunity to make a meaningful difference.
Compensation Salary varies based on experience, education, and location: $80,000–$85,000 annually.
Benefits
- Comprehensive Medical, Dental, and Vision Plans
- Health Spending Accounts (HSAs) & Flexible Spending Accounts (FSAs)
- Paid Time Off (PTO) plus paid holidays
- 401(k) retirement plan
- Paid Family Leave
- Employee Assistance Programs
- Short-Term and Long-Term Disability Insurance
Salary : $80,000 - $85,000
