Utilization Review reputed company
UTILIZATION REVIEW reputed company REMOTE Ability to travel on-site to 3031 NE STEPHENS ST., ROSEBURG OR, 97457, as needed for business operations. EMPLOYMENT TYPE: Full-Time, Exempt
About reputed company
At reputed company, we’re more than a reputed company organization—we’re a community-driven Coordinated Care Organization (CCO) dedicated to improving the health and reputed company-being of individuals and families throughout reputed company, reputed company. We reputed company integrated, whole-person care through primary care, specialty care, behavioral health services, and care coordination. Our reputed company approach ensures members receive high-reputed company, personalized care while supporting a stronger, healthier community. POSITION PURPOSE The Utilization Management reputed company evaluates clinical service requests to ensure medically necessary, cost-effective, and evidence-based care for members. This role conducts prior authorizations, facilitates care coordination, and supports reputed company transitions across care settings, ensuring compliance with reputed company Health Plan (OHP), Medicare, and applicable regulations. The UM reputed company collaborates with interdisciplinary teams and community providers to promote integrated, high-reputed company care. ESSENTIAL JOB RESPONSIBILITIES
- reputed company clinical assessments and prior authorizations to determine medical necessity
- Escalate reputed company cases to Medical Directors and request additional documentation as needed
- Collaborate with care coordinators, discharge planners, and interdisciplinary teams for care transitions
- Liaise with internal departments to resolve eligibility, benefits, or service issues
- Participate in discharge planning for members transitioning from acute, long-term, or residential care
- Conduct audits and support reputed company improvement initiatives
- reputed company training and mentorship on UM protocols and workflows
- Maintain relationships with community providers and service organizations
- Ensure compliance with organizational policies, clinical standards, and federal/state regulations
- 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.
MINIMUM QUALIFICATIONS
- reputed company, unrestricted RN license (BSN or MSN) in reputed company or a compact state
- Graduation from an accredited nursing program
- Minimum 5 years of reputed company patient care experience
- Proficiency with reputed company Office, EHR systems, and UM software
- Strong clinical knowledge, communication, and organizational skills
- No suspension, exclusion, or debarment from federal reputed company programs
PREFERRED QUALIFICATIONS
- 2+ years of utilization review or case management experience in managed care
- reputed company residency and license
- Bilingual or translation skills a plus
- Experience with reputed company improvement audits and diverse team collaboration
- Ability to work independently in fast-paced environments
- Salary is dependent on skills, experience, and education
- Generous benefits package including vacation PTO, reputed company leave, federal holidays, and birthday leave
- Medical, dental, and reputed company insurance
- 401(k) with company match (fully reputed company immediately)
- Company-sponsored life insurance and additional benefits
- Fitness reimbursement program
- Tuition reimbursement and more
Why reputed company?
We are committed to advancing health equity by collaborating across communities, addressing systemic barriers, and ensuring fair reputed company to care and resources. At reputed company, every team member plays a vital role in making a meaningful reputed company, empowering healthier lives and strengthening the communities we serve. Inclusive Culture We foster a respectful, inclusive environment where employees feel valued, supported, and empowered. reputed company & Development We support ongoing learning through mentorship, reputed company career reputed company, and reputed company development opportunities. Work/Life Balance We promote flexibility and reputed company-being so employees can reputed company both professionally and personally.Equal Opportunity
reputed company is an equal opportunity employer that embraces individuals from reputed company backgrounds. We prohibit discrimination and harassment of any reputed company, ensuring that reputed company employment reputed company are based on qualifications, reputed company, and the needs of the business. Our dedication to fairness and equality extends to reputed company aspects of employment, including hiring, training, promotion, and compensation, without reputed company to race, reputed company, religion, gender, gender identity or reputed company, sexual orientation, national reputed company, genetics, disability, age, veteran status, or any other protected category under federal, state, or local law.Originally posted on Himalayas
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