Utilization Review Specialist – Level 4 Lead

Umpqua Health
May 19, 2023
Roseburg, OR
Job Type


Umpqua Health is a Coordinated Care Organization (CCO) in Roseburg, Oregon that connects over 30,000 Douglas County OHP members to physical, dental, and behavioral health services and benefits through an integrated network of providers. Umpqua Health is currently seeking a Utilization Review Specialist Lead to join our team.

  • Full-time REMOTE position. Must reside in Oregon - Douglas County.
  • Generous benefit package including; PTO, Health/Vision/Dental Insurance, 401k with a company match, gym membership reimbursement and more.
  • Salary is dependent upon experience.

The Utilization Review Specialist provides support to Umpqua Health Alliance (UHA) for the intake, processing of and finalization of all prior authorizations received by Medical Management in compliance with regulatory requirements.


  • Provide support for Utilization Review and Care Coordination as related to the prior authorization process.
  • Manage the receipt of documentation through multiple sources on a daily basis including appeals, grievances, and prior authorizations.
  • Identify incoming documentation requests and redistribute to appropriate individual(s) for processing.
  • Creates processes and provides oversight, support and monitoring of tracking and sorting reports for prior authorization requests and supporting information using current systems and processes.
  • Creates processes and provides oversight, support and monitoring of timely notification of prior authorization determinations.
  • Supervisors' daily management of department telephone coverage with individual login and availability.
  • Monitor and ensure research and responses to requests from internal and external customers regarding prior authorizations are completed.
  • Provide support to the Appeals & Grievances Coordinator as needed through phone coverage, member and provider process questions, fax, and email support, and ensuring PA for upheld appeals are entered correctly for claims payment.
  • Conduct and participate in department trainings, audits, and meetings as required.
  • Maintains, recommends, and monitors regulations and procedures.
  • Review compliance of daily reports.
  • Develop and approve training documents and participate in updates for policies and procedures.
  • Lead internal and external reporting, and train and monitor staff performing these functions.
  • Comply with organization's internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations.
  • Oversee, monitor, and ensure new and cross departmental staff training and onboarding procedures are current and completed.
  • Conduct high level audits and other investigatory activities to identify and rectify process improvement opportunities.
  • Oversee, monitor, and work collaboratively with claims and provider networking department to problem solve and communicate with internal and external stakeholder of changes or improvements in processes. This include developing educational materials to be managed on the UHA website, provider newsletter, talking points and department trainings.
  • Assist manager and director with administrative support tasks, such as meetings, employee engagement opportunities and communications.
  • Create, evaluation and analyze reports to write reports and narratives.
  • Comply with organization's internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations.
  • Conduct interviews, evaluation of staff, and new-hire onboarding practices.
  • Provides oversight, monitoring and training on receiving HRS flexible spending requests via fax, email, referral, and case management platforms. Includes entering requests into systems for tracking and review. Validates requests for completion and completes notices for outcomes to member and submitter.
  • Provides oversight, monitoring and training on payment and tracking of flexible spending requests. Maintaining documentation and completion of requests.
  • Perform basic time management duties (PTO requests, leave, timecards, etc.).
  • Staff coaching and performance management as needed.
  • Oversee the daily activities of team.
  • In collaboration with Leadership, ensure staff have daily huddle for new tasks, updates, and task assignment.
  • Ensure coverage when staff call out and provide temporary coverage workflow to all staff.
  • Ensure all team members are current with workload, monitoring productivity and staffing sufficiency.
  • Ensure all patient calls and emails are returned by end of business by all staff.
  • Assign extra duties to staff when needed to fulfill needs of department.
  • Work collaboratively with leadership and staff to ensure efficient, system wide processes are in place.
  • Create and update workflows and operating procedures as needed.
  • Make recommendations and assist with department policies.
  • Understand CCO regulations with OHA contract.
  • Assist Leadership with accurate and timely completion of contract deliverables and internal KPI's.
  • Oversee the career pathing, growth, and performance improvement of staff.
  • Complexity of duties may vary based on the level of experience, education, and qualifications.


Minimum Qualifications:

  • High school diploma or equivalent.
  • 5+ years as a utilization review specialist, medical coding, claims or equivalent managed care experience.
  • Supervisory experience in related field.
  • Experience in quality improvement initiatives and population health management.
  • Prior experience in a customer service and/or clinical setting.
  • Proficient knowledge and understanding of medical terminology, coding and claims.
  • Advanced PC navigational, MS Office (Word, Excel, Outlook), data entry, and internet research skills required. This includes managing data within Excel reports through pivot tables, sorting, filtering, and managing big data. In addition, creating PowerPoint presentations, Visio workflows and documentation management.
  • Proficiency with basic office equipment skills such as computer keyboarding, web-based phone queues and systems, cloud-based document storage, etc.
  • Ability to type at least 45 wpm with a high degree of accuracy required.
  • No suspension/exclusion/debarment from participation in federal health care programs (e.g., Medicare/Medicaid)

Preferred Qualifications:

  • CNA, MA, or medical certification.
  • Degree in Health Care.
  • Some program management experience.
  • Maintain understanding and knowledge of the laws, regulations, policies, and evidence-based, clinical criteria governing Oregon Health Plan (OHP) and Coordinated Care Organizations (CCO). This includes but is not limited to: Oregon Administrative Rules (OAR), Code of Federal Regulations (CFR), Oregon State Legislature (ORS), Prioritized List of Health Services, Division of Medical Assistance Program (DMAP) and Centers for Medicare and Medicaid Services (CMS).
  • Advanced understanding of medical and behavioral health benefit and coverage requirements; able to effectively communicate technical changes and onboard/train new staff. This includes understanding Oregon Health Plan, fee-for-service, claims payment, researching resources and requirements.
  • Knowledge of medical terminology, procedure codes and diagnosis codes.
  • Ability to manage multiple priorities with attention to detail and follow-up.
  • Ability to organize work and remain focused under stressful conditions with critical attention to detail for accuracy and timeliness.
  • Ability to work effectively with a team, other departments, and exercise sound judgment in handling assigned tasks including maintenance of strict confidentiality.
  • Proficient understanding of medical terminology.
  • Ability to interact effectively and professionally with internal and external customers.
  • Experience considering the impacts of the work on multiple communities, including communities of color, in technical analysis.
  • Experience working on a diverse team with different communication styles.
  • Advanced data analytics skills; able to determine data fields, parameters, and run ad hoc reporting with little support.
  • Must be able to be self-disciplined to meet deadlines and follow policies, procedures, and workflows in a remote environment.
  • Ability to meet productivity standards, organize work and remain focused under stressful conditions with critical attention to detail for accuracy and timeliness.
  • Must be able to organize and prioritize work, be proactive, take initiative, follow through, and simultaneously manage multiple priorities to ensure goals are met in a timely manner. High attention to detail.
  • Advanced written, verbal, and interpersonal communication skills; able to communicate with leadership, external stakeholders, vendors, and clients effectively and succinctly.
  • Advanced skills in customer service to internal and external customers.
  • Ability to effectively collaborate with others and function as a part of a highly functioning team. Lead by example to model guiding behaviors (see below).
  • Ability to work effectively with a team, other departments, and exercise sound judgment in handling assigned tasks including maintenance of strict confidentiality.
  • Ability to work well in team setting, as well as independently, and be flexible and adapt to different dynamics in a fast-paced work environment. Ability to work remotely.
  • Advanced critical thinking and time management skills required to organize and prioritize workload according to goals and specified turnaround times.
  • Demonstrated transferable knowledge, skill, and ability to complete job duties independently and proficiently.
  • Willingness to learn new skills and take on new responsibilities.
  • Advanced ability to perform quality improvement audits and report findings. Knowledge of principles of quality improvement and in quality improvement initiatives.
  • Strong knowledge of available community resources.
  • Demonstrated competency working with people from diverse cultures. Ability to assess and treat clients in a culturally competent manner.

For more information or to apply visit our website at www.umpquahealthcareers.com


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