Utilization Review Nurse
U
Umpqua HealthHealthcare Administration
United States, Monday through Friday - 8:00am - 5:00pmFull-TimeMiddle
Salary85,000 - 105,340 USD per year
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Job Details
- Experience
- Minimum 5 years of direct patient care experience
- Required Skills
- Microsoft OfficeEHR
Requirements
- Active, unrestricted RN license (BSN or MSN) in Oregon or a compact state.
- Graduation from an accredited nursing program.
- Minimum 5 years of direct patient care experience.
- Proficiency with Microsoft Office.
- Experience with EHR systems and UM software.
- Strong clinical knowledge, communication, and organizational skills.
- No suspension, exclusion, or debarment from federal healthcare programs.
- 2+ years of utilization review or case management experience in managed care preferred.
- Oregon residency and license preferred.
- Experience with quality improvement audits and diverse team collaboration preferred.
Responsibilities
- Perform clinical assessments and prior authorizations to determine medical necessity.
- Escalate complex 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 quality improvement initiatives.
- Provide 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.
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