Utilization Review Nurse

POSITION PURPOSE

The Utilization Management Nurse (UM Nurse) is responsible for evaluating clinical service requests to ensure medically necessary, cost-effective, and evidence-based care for members. This role conducts prior authorizations, facilitates care coordination, and supports transitions across care settings while ensuring compliance with Oregon Health Plan (OHP), Medicare, and other regulatory guidelines. The UM Nurse collaborates with interdisciplinary teams and community providers to promote high-quality, integrated care.

ESSENTIAL JOB RESPONSIBILITIES

Conduct clinical assessments and prior authorizations to determine medical necessity and appropriateness of services Escalate complex cases to Medical Directors and request additional clinical documentation as needed Collaborate with care coordinators and interdisciplinary teams to support care transitions Maintain up-to-date knowledge of OHP, Medicare, and applicable regulatory requirements Serve as a liaison with internal departments to resolve eligibility, benefits, or service concerns Participate in discharge planning and support continuity of care across settings Conduct audits and contribute to quality improvement initiatives Provide training and mentorship on clinical workflows and UM protocols Ensure compliance with organizational policies and federal/state regulations

Minimum Qualifications:

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 in a clinical setting Proficiency in Microsoft Office and electronic health record (EHR) systems Strong communication, collaboration, and problem-solving skills No suspension, exclusion, or debarment from federal healthcare programs (Medicare/Medicaid)

Preferred Qualifications:

2+ years of utilization review or case management experience in managed care or commercial insurance Knowledge of contractual benefits and alternative coverage options Experience conducting quality improvement audits Bilingual or translation skills a plus Ability to work independently and in fast-paced environments

Salary:

Wage Band 20: $ 85,990 - $ 105,3440 Salary is dependent upon skills, experience, and education. Generous benefit packages include PTO, Sick Leave, and Federal Holidays. Health/Vision/Dental Insurance including other company sponsored benefits. 401k with a company match Gym Membership Reimbursement Tuition Reimbursement, and more. Full-time position. Must reside in Oregon. 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.

Pay:

$85,990.00 - $105,344.00 per year

Benefits:

401(k) matching Dental insurance Disability insurance Flexible spending account Health insurance Health savings account Life insurance Paid time off Parental leave Retirement plan Travel reimbursement Tuition reimbursement Vision insurance

Work Location:

Hybrid remote in Roseburg, OR 97470