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Utilization Review Coordinator

Umpqua Health
Full-time
Remote
United States
$85,000 - $124,000 USD yearly
Utilization Review
Job Description
JOB TITLEUtilization Review CoordinatorREPORTS TOUtilization Review, Manager
STATUSFT, ExemptWAGE RANGEGrade 20 (2024)
DEPARTMENTUtilization ReviewWORK LOCATIONRemote (occasional travel as required)
 
POSITION PURPOSE
The Utilization Review Coordinator (URC), is a remote position that 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 utilization review coordinator will adhere to regulatory compliance requirements, department quality metrics and provide exceptional customer service to all internal and external customers.
 
ESSENTIAL JOB RESPONSIBILITIES
  • Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and internal and external guidelines.
  • Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
  • Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
  • Conducts prior authorization and HRS flex reviews to determine medical necessity and appropriateness of services and financial responsibility.
  • Processes requests within required timelines.
  • Refers appropriate prior authorization and HRS flex requests to Medical Directors.
  • Requests additional information from members or providers in a consistent and efficient manner.
  • Makes appropriate referrals to other clinical programs.
  • Collaborate with multidisciplinary teams to work with the care coordinators to ensure members receive integrated care coordination as needed.
  • Adheres to Umpqua Health policies and procedures and State, Federal and local regulations.
  • Advanced knowledge of the Oregon Administrative Rules (OAR) governing the Oregon Health Plan as well as all applicable Medicare guidelines. Referring to OHP/ Medicare websites as needed. This includes the understanding of the policies and procedures that apply to the Appeal and Grievance process and the Member’s Rights and responsibilities as stated by the Division of Medical Assistance Program (DMAP) as well as CMS.
  • Ability to demonstrate an ongoing understanding and current knowledge of benefits for OHP/Medicare required.
  • Work together with the Third-Party Recovery (TPR) department regarding any member with the potential for additional insurance coverage as well as reporting any case that may reach a stop loss.
  • Work with the Customer Care department regarding eligibility issues including when a member has a change in address or moved out of area.
  • Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost-effective care delivery.
  • Responsible for ensuring that the treatment delivered is appropriately utilized and meets the members’ needs in the least restrictive, least intrusive manner possible.
  • Conduct low level audits to identify and rectify process improvement opportunities.
  • Understand and participate in the discharge planning associated with inpatient/residential prior authorization reviews to ensure treatment plans and transitions of care are successful for members transferring to higher or lower levels of care within an allotted timeframe.
  • Train new and cross departmental staff with onboarding procedures as needed.
  • Assist in transition/ Establish Establishes and maintains relationships with community services and providers es and maintains relationships with community services and providers discharge planning for members discharging from acute care settings or those who are transitioning from long term care, the Oregon State Hospital, or other residential facilities to ensure a smooth transition back to community-based supports.
  • Ensure discharge/transition plans are evaluated holistically from physical and behavioral health perspectives.
  • Strong knowledge of available community resources
  • Other duties as assigned.
 
CHALLENGES
  • Working with a variety of personalities, maintaining a consistent and fair communication style.
  • Satisfying the needs of a fast paced and challenging company.
 
QUALIFICATIONS
Minimum Qualifications
  • RN preferred, will consider LPN/LVN. Varied medical experience and capability required.
  • Proficient knowledge and understanding of medical processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits.
  • Maintain understanding 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).
  • 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.
  • Knowledge of basic data analytic skills.
  • Experience following established medical/clinical guidelines
  • Interpersonal, written, and oral communication skills.
  • Establishes and maintains relationships with community services and providers
  • No suspension/exclusion/debarment from participation in federal health care programs (e.g. Medicare/Medicaid)
  • Proficient computer skills, including MS Office suite.

Preferred Qualifications
  • Experienced in performing utilization reviews to assess and authorize medical service requests.
  • 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.
  • 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 use computerized systems for data recording and retrieval.
  • Ability to work well in team setting, as well as independently, be flexible and adapt to different dynamics in a fast-paced
  • work environment.
  • Advanced proficiency with 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.
  • Ability to support organizational and program-specific mission and goals.
  • Understanding of contractual benefits and options available outside contractual benefits.
  • Assures patient confidentiality, privacy, and health records security.
  • Maintains current clinical knowledge base and certification.
  • Ability to work independently with minimal supervision.
  • Must be able to function as part of a collaborative, cohesive community.
  • Demonstrated ability to identify barriers to a successful care management path.
  • Working knowledge of community services, providers, vendors, and facilities available to assist members.
  • Assures patient confidentiality, privacy, and health records security.
  • Develop analytical and strategic problem-solving skills.
  • Ability to perform quality improvement audits and report findings.
  • Advanced proficiency with self-discipline to meet deadlines and follow policies, procedures, and workflows in a remote environment.
  • Ability to organize work and remain focused under stressful conditions with critical attention to detail 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.
  • 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.
  • Bi-lingual translation or translation capabilities 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 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.
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.

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