Utilization Review Nurse

Remote

Full Time

Utilization Management

Mid Level

UTILIZATION REVIEW NURSE

HYBRID, must be able to travel to 3031 NE STEPHENS ST. ROSEBURG, OR 97470

EMPLOYMENT TYPE: Full-Time, Exempt

About Umpqua Health

At Umpqua Health, we’re more than a healthcare organization—we’re 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. Our collaborative approach ensures members receive high-quality, personalized care while supporting a stronger, healthier community.

POSITION PURPOSE
The Utilization Management Nurse evaluates clinical service requests to ensure medically necessary, cost-effective, and evidence-based care for members. This role conducts prior authorizations, facilitates care coordination, and supports safe transitions across care settings, ensuring compliance with Oregon Health Plan (OHP), Medicare, and applicable regulations. The UM Nurse collaborates with interdisciplinary teams and community providers to promote integrated, high-quality care.

ESSENTIAL JOB RESPONSIBILITIES

Perform clinical assessments and prior authorizations to determine medical necessity
Escalate complex cases to Medical Directors and request additional documentation as needed
Collaborate with care coordinators, discharge planners, and interdisciplinary teams for care transitions
Liaise with internal departments to resolve eligibility, benefits, or service issues
Participate in discharge planning for members transitioning from acute, long-term, or residential care
Conduct audits and support quality improvement initiatives
Provide training and mentorship on UM protocols and workflows
Maintain relationships with community providers and service organizations
Ensure compliance with organizational policies, clinical standards, and federal/state regulations
Perform other nursing-related duties as assigned

CHALLENGES

Working with a variety of personalities, maintaining a consistent and fair communication style.
Satisfying the needs of a fast-paced and challenging company.

MINIMUM QUALIFICATIONS

Active, unrestricted RN license (BSN or MSN) in Oregon or a compact state
Graduation from an accredited nursing program
Minimum 5 years of direct patient care experience
Proficiency with Microsoft Office, EHR systems, and UM software
Strong clinical knowledge, communication, and organizational skills
No suspension, exclusion, or debarment from federal healthcare programs

PREFERRED QUALIFICATIONS

2+ years of utilization review or case management experience in managed care
Oregon residency and license
Bilingual or translation skills a plus
Experience with quality improvement audits and diverse team collaboration
Ability to work independently in fast-paced environments

SCHEDULE
Monday through Friday - 8:00am - 5:00pm; standard business hours with flexibility to meet service timelines.

SALARY
Wage Band: $85,000- $105,340

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

Why Umpqua Health?

We are committed to advancing health equity by collaborating across communities, addressing systemic barriers, and ensuring fair access to care and resources. At Umpqua Health, every team member plays a vital role in making a meaningful impact, empowering healthier lives and strengthening the communities we serve.

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.

Equal Opportunity

Umpqua Health is an equal opportunity employer that embraces individuals from all backgrounds. We prohibit discrimination and harassment of any kind, ensuring that all employment decisions are based on qualifications, merit, and the needs of the business. Our dedication to fairness and equality extends to all aspects of employment, including hiring, training, promotion, and compensation, without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other protected category under federal, state, or local law.

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Utilization Review Nurse

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