Job Description| JOB TITLE | Utilization Review Specialist I | REPORTS TO | Utilization Review Manager |
| STATUS | FT, Non-Exempt | WAGE RANGE | Grade 13 (2024) |
| DEPARTMENT | Utilization Review | WORK LOCATION | Roseburg, Or |
| POSITION PURPOSE |
| The Utilization Review Specialist I 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. |
| ESSENTIAL JOB RESPONSIBILITIES |
- Provide support for Utilization Review and Care Coordination as related to the prior authorization process.
- Manage the receipt of documentation through multiple sources daily including appeals, grievances, and prior authorizations.
- Identify incoming documentation requests and redistribute to appropriate individual(s) for processing.
- Tracks and sorts prior authorization requests and supporting information using current systems and processes.
- Support the timely notification of prior authorization determinations.
- Coordinate with other Utilization Review Specialists for daily management of department telephone coverage with individual login and availability.
- Research and respond to requests from internal and external customers regarding prior authorizations. Refer members and providers to other appropriate staff as necessary.
- Provide support to the Appeals & Grievances Coordinator as needed.
- Participate in department training, audits, and meetings as needed.
- Maintain a solid understanding of regulations and procedures.
- Monitor daily reports for compliance.
- Comply with organization’s internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations.
- Other duties as assigned.
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| CHALLENGES |
- Working with a variety of personalities, maintaining a consistent and fair communication style.
- Satisfying the needs of a fast-paced and challenging company.
- Interaction with a variety of personalities.
- Working in a fast-paced environment with shifting priorities.
- Coordinating resources to achieve goals and objectives.
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| QUALIFICATIONS |
Minimum Qualifications- High school diploma or equivalent.
- Proficient PC navigational, MS Office (Word, Excel, Outlook), data entry, and internet research skills.
- 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.
- High attention to detail.
- No suspension/exclusion/debarment from participation in federal health care programs (e.g., Medicare/Medicaid)
- No suspension/exclusion/debarment from participation in federal health care programs (eg. Medicare/Medicaid)
- Proficient computer skills, including MS Office suite
- Preferred Qualifications
- Experience considering the impacts of the work on multiple communities, including communities of color, in technical analysis.
- Experience working on a diverse team
- Experience working with different communication styles
- Bi-lingual translation or translation capabilities a plus
- 1+ years’ experience in the medical field, managed care (utilization), medical coding, claims or related field.
- 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).
- 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.
- 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.
- Proficient interpersonal, written, and oral communication skills.
- Proficient 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.
- 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 a team setting, as well as independently, and be flexible and adapt to different dynamics in a fast-paced work environment. Ability to work remotely Monday-Friday 8:00-5:00 PST
- Proficient critical thinking and time management skills required to organize and prioritize workload according to goals and specified turnaround times.
- Willingness to learn new skills and take on new responsibilities.
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| PHYSICAL DEMANDS |
| A typical office environment requires standing, sitting, walking, bending, and lifting up to 25 plus pounds. |
| EQUAL EMPLOYMENT OPPORTUNITY |
UH is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. UH makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, read through our EEO Policy. |
| JOB DESCRIPTION ACKNOWLEDGEMENT |
| I have reviewed the attached job description as outlined above and understand that I am responsible for all duties as outlined and other tasks as may be assigned. I understand that if I need accommodation to perform the essential functions of my job that I must contact my supervisor or Human Resources as soon as possible to begin an interactive process. |
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| Note: This job description 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-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise, other than an “at will” relationship. |
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.
