Utilization Review Specialist

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.
• Cook 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
• Able to manage shifting priorities in a fast-paced environment
• Able 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.
• Able 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
• Able to meet deadlines while maintaining accuracy and attention to detail
• Strong communication and customer service skills (written, verbal, and interpersonal)
• Able 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
• Able 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.

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.