Job Description

Umpqua Health is recruiting a Utilization Review Specialist to support our mission of delivering high-quality, cost-effective healthcare services. In this role, you’ll play a key part in ensuring that requested medical services are appropriate, necessary, and aligned with clinical and regulatory standards. You’ll review prior authorization requests, process clinical documentation, and collaborate with providers to ensure timely and accurate service approvals. Your work will directly contribute to the efficient use of healthcare resources and improved health outcomes for our members. 

Your Impact: 

• Review and process prior authorization requests received via phone, voicemail, and email, entering data accurately into the utilization management system. 
• Gather and organize relevant clinical documentation for medical necessity reviews in accordance with organizational policies. 
• Communicate authorization outcomes to providers in a timely manner and in alignment with policies and procedures. 
• Draft and issue coverage determination letters, ensuring clarity, compliance, and consistency with clinical review outcomes. 
• Work within electronic medical records (EMR) and utilization management platforms to document and manage cases. 
• Monitor high-volume workloads while maintaining accuracy, prioritization, and compliance with turnaround requirements. 
• Support coordination of services with providers to facilitate timely care delivery and improve the member experience. 
• Collaborate with internal departments to support authorization workflows and identify opportunities for process improvement. 
• Participate in departmental initiatives and contribute to achieving organizational goals related to quality, efficiency, and regulatory compliance. 
• Perform other duties as assigned to support Umpqua Health’s Vision, Mission, and Organizational Values. 

Your Credentials: 

• High school diploma or equivalent required; additional training or coursework in medical terminology or health sciences preferred. 
• Minimum of one (1) year of experience in utilization review, prior authorization, or related healthcare operations role. 
• Demonstrated proficiency in using computer systems, including Microsoft Office Suite (Word, Excel, Outlook) and EMR/utilization management platforms. 
• Familiarity with CPT codes, ICD-10 codes, and standard medical terminology strongly preferred. 
• Strong communication and interpersonal skills, with the ability to interact effectively with healthcare providers and interdisciplinary teams. 
• Exceptional organizational and time-management skills, with the ability to prioritize tasks in a fast-paced environment. 
• Analytical thinker with a detail-oriented approach to reviewing clinical documentation and applying policy criteria. 
• Experience in a medical office, hospital, or payer environment preferred. 
• Must maintain professionalism, confidentiality, and adherence to HIPAA and regulatory guidelines. 

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.

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