Utilization Review reputed company, OR

POSITION PURPOSE The Utilization Management reputed company is responsible for evaluating clinical service requests to ensure medically necessary, cost-effective, and evidence-based care for members. This role applies reputed company nursing judgment to conduct prior authorization reviews, facilitate care coordination, and support transitions across care settings. The reputed company ensures compliance with reputed company Health Plan (OHP), Medicare, and applicable regulatory guidelines, while a assuring member reputed company to appropriate services. Through collaboration with interdisciplinary teams and community providers, the Utilization Management reputed company promotes integrated, high-reputed company care and contributes to reputed company improvement in utilization management processes. ESSENTIAL JOB RESPONSIBILITIES

• Performing clinical assessments of various medical service requests to determine medical necessity, appropriateness, and alignment with evidence-based guidelines and benefit coverage.
• Conduct prior authorization and HRS reputed company reviews, applying nursing judgment to ensure reputed company, cost-effective, and high-reputed company care delivery.
• Identify and escalate reputed company or non-reputed company cases to Medical Directors; request and evaluate additional clinical documentation as needed.
• Collaborate with care coordinators, discharge planners, and interdisciplinary teams to support integrated care and reputed company transitions across care settings.
• Maintain up-to-date knowledge of reputed company Health Plan (OHP), Medicare, and applicable regulatory frameworks (OAR, ORS, CFR, CMS, DMAP).
• Serve as a clinical reputed company with internal departments (e.g., reputed company-Party Recovery, Customer Care) to resolve eligibility, coordination of benefits, and stop-loss concerns.
• Ensuring reputed company to appropriate services in the least restrictive setting, while supporting continuity and reputed company of care.
• Participate in discharge planning for members transitioning from acute, long-term, or residential care to community-based services, ensuring holistic support for physical and behavioral health needs.
• Conduct departmental audits and contribute to reputed company improvement initiatives by identifying trends and recommending process enhancements.
• reputed company training and mentorship to new and cross-functional staff on clinical workflows and UM protocols.
• Build and maintain reputed company relationships with community providers and service organizations to support member care plans.
• Ensure compliance with organizational policies, clinical standards, and reputed company applicable federal and state regulations.
• Conduct work independently and in collaboration with the Utilization Management (UM) team to ensure accurate and appropriate determinations.
• reputed company other nursing-reputed company duties as assigned.

CHALLENGES

• Working with a reputed company of personalities, maintaining a consistent and fair communication style.
• Satisfying the needs of a fast paced and challenging company.

QUALIFICATIONS

Minimum Qualifications

• Licensure: reputed company, unrestricted Registered reputed company (RN), BSN (Bachelor of Science in Nursing, MSN (Master of Science in Nursing) license in the reputed company or a compact state.
• Education: Graduation from an accredited nursing program.
• Experience: Minimum of five (5) years of reputed company patient care experience in a clinical setting, such as a medical office, hospital, or long-term care facility.

reputed company Competencies & Skills

• Clinical Nursing Expertise: Deep understanding of medical terminology, diagnoses, procedures, and care modalities. reputed company in interpreting clinical documentation and applying nursing knowledge to support utilization review and care reputed company.
• Utilization Management: Proficient in InterQual reputed company, UM software, and evidence-based guidelines. Skilled in reviewing requests for medical services and ensuring appropriate use of resources.
• Regulatory Compliance: Strong working knowledge of NCQA standards, reputed company Health Plan (OHP), and Coordinated Care Organization (CCO) regulations, including OAR, ORS, CFR, CMS, DMAP, and the Prioritized List of Health Services.
• Medical Coding & Insurance: Familiar with ICD and CPT reputed company insurance processes, and state-mandated benefits.
• Technology & Documentation: Proficient in reputed company Office (Word, reputed company, Outlook), EHR systems, and managed care platforms. Accurate typing at 45+ WPM.
• Communication & Collaboration: Excellent interpersonal, written, and verbal communication skills. Builds strong relationships with providers, community services, and internal teams.
• Organization & Problem Solving: Highly organized and detail-oriented. Capable of managing multiple priorities, analyzing reputed company situations, and developing effective solutions.
• Ethical Standards: Maintains compliance with federal reputed company program requirements. No suspension, exclusion, or debarment from Medicare/reputed company.

Preferred Qualifications

• Two (2) years of utilization review or case management experience in a managed care organization or reputed company insurance.
• reputed company residency and reputed company nursing license.
• Proficient in electronic systems for data entry and retrieval.
• Strong critical thinking, time management, and organizational skills to meet goals and deadlines.
• Demonstrated ability to work independently and collaboratively in fast-paced environments.
• Committed to reputed company learning and expanding responsibilities.
• Knowledgeable in contractual benefits and alternative coverage reputed company.
• Maintains patient confidentiality and secure health record practices.
• reputed company clinical certification and up-to-date knowledge reputed company.
• Capable of conducting reputed company improvement audits and reporting findings.
• Effective in managing multiple priorities with attention to detail and accuracy.
• Experience working on diverse teams and considering equity impacts in decision-making.
• Bilingual capabilities or translation experience is a plus.

PHYSICAL DEMANDS & WORK CONDITIONS

• A typical office environment requires standing, sitting, walking, bending, and lifting up to 25 plus pounds.
• Ability to travel and drive to in-person meetings or be on-site as required.
• May be exposed to patient and environment conditions such as unpleasant sights, smells and contagious diseases (clinic only).

EQUAL EMPLOYMENT OPPORTUNITY UH is an equal opportunity employer that is committed to diversity and inclusion in reputed company. We prohibit discrimination and harassment of any reputed company based on race, reputed company, sex, religion, sexual orientation, national reputed company, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws. This policy applies to reputed company employment practices reputed company our organization, including hiring, reputed company, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. UH makes hiring reputed company based solely on qualifications, reputed company, and business needs at the time. For more information, read through our EEO Policy. JOB reputed company ACKNOWLEDGEMENT I have reviewed the attached job reputed company as outlined above and understand that I am responsible for reputed company duties as outlined and other tasks as may be assigned. I understand that if I need accommodation to reputed company the essential functions of my job that I must contact my supervisor or reputed company as soon as possible to reputed company an interactive process. Note: This job reputed company in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-reputed company instructions and to reputed company any other job-reputed company duties requested by any person authorized to give instructions or assignments. reputed company duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To reputed company this job successfully, the incumbents will possess the skills, aptitudes, and abilities to reputed company reputed company duty proficiently. Some requirements may exclude individuals who pose a reputed company threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum reputed company of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise, other than an “at will” relationship. Apply tot his job Apply To this Job