The Role:
As a Utilization Review Specialist, you will be responsible for ensuring that healthcare services are medically necessary, efficiently provided, and appropriately utilized. This role involves reviewing patient medical records, assessing and evaluating requests for medical services, treatments, or procedures to determine their appropriateness, and ensuring compliance with regulatory and payer requirements. You will also play a key role in the intake, processing, and finalization of all prior authorizations received by the Medical Management team, coordinating with healthcare providers to facilitate accurate and timely approval of services. Your work will directly support the goal of delivering high-quality, cost-effective care.
Your Impact:
- Performs data entry of authorization information (per policy/procedure) into web-based system as received through telephone calls, voice mail messages and emails.
- Gathers and organizes clinical information for review.
- Communicates authorization request status to the providers as per policy and procedure.
- Writes coverage determination letters.
- Works with computer/electronic medical records daily.
- Perform other duties as assigned by management to help drive our Vision, fulfill our Mission, and abide by our Organization’s Values.
Your Credentials:
- High School Diploma or equivalent work experience.
- Demonstrate a proficiency in computer skills, Windows, Word, Excel, Outlook, clinical platforms, internet searches
- Knowledge of ICD 10 codes, CPT codes and medical terminology a bonus.
- Excellent organizational and communication skills.
- Ability to be flexible and work in a fast-paced office environment.
- Ability to prioritize a high volume of work.
- Medical office or hospital experience preferred but not required
- Excellent analytical and critical thinking skills.
- Strong communication and interpersonal skills, with the ability to work effectively with healthcare providers, patients, and insurance companies.
- Proficient in using electronic medical records (EMR) systems and utilization management software.
Disclaimer
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.