Utilization Review Specialist
Umpqua Health is seeking a Utilization Review Specialist to join our team in advancing our mission of delivering high-quality, cost-effective, and person-centered healthcare services. In this role, you will play a vital part in ensuring that requested medical services are appropriate, necessary, and aligned with clinical and regulatory standards. Your contributions will help promote equitable access to care and support improved health outcomes for our diverse member population.
As a Utilization Review Specialist, you will be responsible for reviewing prior authorization requests received through various channels, including phone, voicemail, and email. You will accurately enter data into the utilization management system and gather relevant clinical documentation to support medical necessity reviews in accordance with organizational policies. Your role includes communicating authorization outcomes to providers in a timely and respectful manner, drafting clear and compliant coverage determination letters, and documenting cases within electronic medical records (EMR) and utilization management platforms.
You will be expected to manage a high volume of work while maintaining accuracy, prioritization, and compliance with turnaround requirements. In collaboration with providers, you will help coordinate services to ensure timely care delivery and enhance the member experience. Additionally, you will work closely with internal departments to support authorization workflows and identify opportunities for continuous improvement. Your participation in departmental initiatives will contribute to achieving organizational goals related to quality, efficiency, and regulatory compliance. Other duties may be assigned to support Umpqua Health’s Vision, Mission, and Organizational Values.
Qualifications:
- A high school diploma or equivalent is required; additional training or coursework in medical terminology or health sciences is preferred.
- At least one (1) year of experience in utilization review, prior authorization, or a related healthcare operations role is required.
- Proficiency in using computer systems, including Microsoft Office Suite (Word, Excel, Outlook), and EMR/utilization management platforms is essential.
- Familiarity with CPT codes, ICD-10 codes, and standard medical terminology is strongly preferred.
- Strong communication and interpersonal skills are necessary to engage effectively with healthcare providers and interdisciplinary teams.
- Exceptional organizational and time-management skills are required, along with the ability to prioritize tasks in a dynamic, fast-paced environment.
- A detail-oriented and analytical approach to reviewing clinical documentation and applying policy criteria is essential.
- Experience in a medical office, hospital, or payer environment is preferred.
- The ability to maintain professionalism, confidentiality, and adherence to HIPAA and regulatory guidelines is required.
About Umpqua Health
At Umpqua Health, we're more than just a healthcare organization; we're a community-driven Coordinated Care Organization (CCO) committed to improving the health and well-being of individuals and families throughout our region. Umpqua Health serves Douglas County, Oregon, where we prioritize personalized care and innovative solutions to meet the diverse needs of our members. Our comprehensive services include primary care, specialty care, behavioral health services, and care coordination to ensure our members receive holistic, integrated healthcare. Our collaborative approach fosters a supportive environment where every team member plays a vital role in our mission to provide accessible, high-quality healthcare services. From preventative care to managing chronic conditions, we're dedicated to empowering healthier lives and building a stronger, healthier community together. Join us in making a difference at Umpqua Health.
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.