Company Overview
Umpqua Health is seeking a dedicated and detail-oriented Utilization Review Coordinator to support our mission of providing timely, appropriate, and high-quality care to our members. This pivotal role involves evaluating medical necessity for service authorizations, coordinating care with providers, and applying clinical standards and regulatory guidelines to ensure our members—particularly those with complex care needs—receive the services they require.
Key Responsibilities:
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Conduct Utilization Reviews:
Evaluate clinical documentation for prospective, concurrent, and retrospective authorization requests across medical, behavioral health, and substance use treatment services. -
Apply Clinical Standards:
Use evidence-based criteria and regulatory frameworks such as Oregon Health Plan guidelines, InterQual criteria, ASAM standards, Medicare regulations, and internal policies to guide decision-making. -
Ensure Quality Documentation:
Clearly and accurately document clinical decisions in accordance with state and federal regulations, internal protocols, and audit standards. -
Facilitate Continuity of Care:
Identify members who may benefit from case management or care coordination and make appropriate internal referrals. Support transitions of care from inpatient or out-of-network settings to ensure seamless service delivery. -
Collaborate with Providers and Partners:
Serve as a liaison between Umpqua Health and contracted/non-contracted providers to assist with care planning, authorization clarification, and rate negotiations. -
Track Utilization Trends:
Monitor service utilization patterns and contribute to process improvement initiatives aimed at enhancing compliance and service delivery outcomes. -
Engage in Departmental Activities:
Participate in audits, performance evaluations, committee meetings, and regulatory reporting. -
Support Internal Teams:
Act as a clinical resource to colleagues, supporting education and cross-functional collaboration within the organization. -
Other Duties as Assigned:
Contribute to Umpqua Health’s Vision, Mission, and Core Values by embracing flexibility and taking on additional responsibilities as needed.
Qualifications:
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Licensure:
Must hold a current and active license in one of the following areas: RN, LPN, RT, LCSW, LPC, LMFT, psychologist, or equivalent.
For behavioral health-focused roles, CADC I or higher is required or must be obtained within 12 months of hire. -
Experience:
Minimum of 3 years of clinical experience in medical, behavioral health, or integrated healthcare settings, especially in roles supporting individuals with complex needs. -
Skills & Competencies:
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Strong clinical judgment and familiarity with managed care principles.
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Excellent written and verbal communication skills.
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Technological proficiency, including use of electronic medical records, Microsoft Office Suite, and virtual communication platforms.
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Ability to manage a dynamic caseload independently, while ensuring compliance with documentation and review timelines.
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Demonstrated success in collaborative, fast-paced healthcare environments.
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Compliance:
Must be in good standing with all applicable licensing boards and not barred from participating in federal healthcare programs (e.g., Medicare, Medicaid).
About Umpqua Health:
Umpqua Health is a mission-driven Coordinated Care Organization (CCO) dedicated to improving the health of individuals and families in Douglas County, Oregon. We offer a comprehensive suite of healthcare services—including primary care, specialty care, behavioral health, and care coordination—with a focus on personalized, integrated care. Our organization thrives on collaboration, compassion, and innovation, with every team member playing a key role in advancing community health outcomes.
Commitment to Diversity and Inclusion:
Umpqua Health is proud to be an Equal Opportunity Employer, committed to creating an inclusive and respectful workplace for all. We make employment decisions based on qualifications, merit, and business needs, without regard to race, color, religion, sex, gender identity, sexual orientation, age, disability, national origin, veteran status, or any legally protected status.