Utilization Review Nurse

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.

The Utilization Management Nurse is responsible for evaluating clinical service requests to ensure medically necessary, cost-effective, and evidence-based care for members. This role applies professional nursing judgment to conduct prior authorization reviews, facilitate care coordination, and support transitions across care settings. The nurse ensures compliance with Oregon Health Plan (OHP), Medicare, and applicable regulatory guidelines, while a assuring member access to appropriate services. Through collaboration with interdisciplinary teams and community providers, the Utilization Management Nurse promotes integrated, high-quality care and contributes to continuous improvement in utilization management processes.

Performing clinical assessments of various medical service requests to determine medical necessity, appropriateness, and alignment with evidence-based guidelines and benefit coverage. Conduct prior authorization and HRS flex reviews, applying nursing judgment to ensure timely, cost-effective, and high-quality care delivery. Identify and escalate complex or non-standard cases to Medical Directors; request and evaluate additional clinical documentation as needed. Collaborate with care coordinators, discharge planners, and interdisciplinary teams to support integrated care and safe transitions across care settings. Maintain up-to-date knowledge of Oregon Health Plan (OHP), Medicare, and applicable regulatory frameworks (OAR, ORS, CFR, CMS, DMAP). Serve as a clinical liaison with internal departments (e.g., Third-Party Recovery, Customer Care) to resolve eligibility, coordination of benefits, and stop-loss concerns. Ensuring access to appropriate services in the least restrictive setting, while supporting continuity and quality of care. Participate in discharge planning for members transitioning from acute, long-term, or residential care to community-based services, ensuring holistic support for physical and behavioral health needs. Conduct departmental audits and contribute to quality improvement initiatives by identifying trends and recommending process enhancements. Provide training and mentorship to new and cross-functional staff on clinical workflows and UM protocols. Build and maintain collaborative relationships with community providers and service organizations to support member care plans. Ensure compliance with organizational policies, clinical standards, and all applicable federal and state regulations. Conduct work independently and in collaboration with the Utilization Management (UM) team to ensure accurate and appropriate determinations. Perform other nursing-related 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.