30 days old

Utilization Coordinator

Umpqua Health
Roseburg, OR 97470
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  • Job Code
Full Time - Regular
Roseburg, OR, US


The Utilization Reviewer Coordinator (URC) performs clinical reviews for Umpqua Health Alliance (UHA) to determine the medical necessity of requested services based on applicable Medicaid/Medicare policies and criteria. The URC will adhere to regulatory compliance requirements, department quality metrics and provide exceptional customer service to all internal and external customers.

  • Review actual and proposed medical care and services compared to established guidelines.
  • Maintain updated knowledge of the Oregon Administrative Rules (OAR) governing the Oregon Health Plan as well as all applicable Medicare guidelines. Referring to DMAP/ Medicare websites as needed. This includes the understanding of the policies and procedures that apply to the Appeal and Grievance process and the Members Rights and responsibilities as stated by the Division of Medical Assistance Program (DMAP) as well as CMS.
  • Demonstrate an ongoing understanding and current knowledge of benefits for OHA/Medicare.
  • Understand and participate in the prior authorization process for procedures, medications, durable medical equipment, admits, referrals and transfers to Skilled Nursing Facilities (SNF) and out-of-area admissions within allotted timeframes.
  • Work together with the Third Party Recovery (TPR) coordinator regarding any member with the potential for additional insurance coverage as well as reporting any case that may reach stop loss.
  • Work with Member Services department with eligibility issues including when a member has a change in address or moved out of area.
  • Make appropriate referrals to Case Management (CM).
  • Consult with Medical Director as needed.
  • Comply with organizations internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations.
  • Complexity of duties may vary based on the level of experience, education and qualifications of coordinator.
  • Other duties as assigned.



Always demonstrate the highest performance and behavior standards. Share responsibility and expect others to be accountable.


Demonstrate a proactive approach to problem identification and solutions. Be innovative and solutions oriented, improving processes while reducing costs. Demonstrate appropriate time-management skills. Optimize the use of available resources.

Be a Team Player

Support and assist your team members. Be available to help, and learn from your team. Keep an open mind to feedback and earn trust of staff.


Keep your promises, commitments, and confidences. Be honest and straightforward dealing with all issues fairly and consistently.


Adhere to all state and federal regulations relating to your position including the Health Insurance Portability and Accountability Act (HIPAA), Fraud & Abuse and Occupational Safety and Health Administration (OSHA) laws. Abide by Company policies and procedures at all times.

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


A current medical licensure is required, type of licensure is based on level of Utilization Review Coordinator;
  • Level 1: Any valid medical license (examples include; MA, LPN, EMT, CNA, RT.) Some medical background preferred.
  • Level 2: MA, LPN, RN, EMT with a minimum of 2 years in utilization review or similar field.
  • Level 3: RN, BSN, LCSW or a minimum of 5 years of experience in utilization review.
  • Level 4: RN, BSN, LCSW, FNP or a minimum of 10 years of experience in utilization review.
  • Previous utilization review experience preferred.
  • Previous experience in a managed care setting preferred.
  • Experience following established medical guidelines required.
  • Clinical knowledge of the health or social work needs for the population served.
  • Demonstrated ability to identify barriers to a successful care management path.
  • Ability to interact effectively and professionally with internal and internal customers.
  • Proficient PC Navigational skills required; solid data entry and MS Office skills required.
  • Excellent critical thinking and time management skills.
  • Excellent written, verbal and interpersonal communication skills, with demonstrated ability to provide exceptional customer service to internal and external customers.
  • Demonstrated transferable knowledge, skill and ability to complete job duties independently and proficiently
  • Current Oregon Drivers license required.


Typical office environment requiring standing, sitting, walking, bending, and lifting up to 25 pounds.


Posted: 2021-05-14 Expires: 2021-06-14

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Utilization Coordinator

Umpqua Health
Roseburg, OR 97470

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