Job Description

Utilization Review Coordinator
Umpqua Health

Umpqua Health is recruiting a Utilization Review Coordinator to support our commitment to delivering timely, appropriate, and high-quality care for our members. In this role, you will be responsible for evaluating authorization requests, coordinating with providers, and applying clinical standards to ensure members receive the care they need when they need it. This position plays a vital role in supporting members—particularly those with complex care needs—by applying evidence-based practices, adhering to regulatory standards, and collaborating across departments to ensure optimal outcomes.

Key Responsibilities
As a Utilization Review Coordinator, you will review clinical documentation for prospective, concurrent, and retrospective authorization requests to determine medical necessity and service appropriateness. You’ll apply Oregon Health Plan guidelines, InterQual criteria, ASAM standards, Medicare regulations, and internal policies to evaluate benefit coverage and ensure compliance.

You will be responsible for clearly documenting clinical decision-making in alignment with state and federal requirements, internal policies, and audit standards. A critical part of your role will be identifying members who may benefit from case management or care coordination and referring them to the appropriate internal teams. You’ll also support transitions of care for members discharged from inpatient, residential, or out-of-network facilities to ensure continuity and avoid service gaps.

In addition, you’ll partner with providers and vendor partners to facilitate care planning, clarify authorizations, and discuss non-contracted rates when necessary. You’ll track and report key utilization trends and contribute to process improvements that enhance service delivery and compliance. Participation in audits, performance reviews, committee meetings, and regulatory reporting activities is also expected. As a clinical resource, you’ll support internal teams through education, mentorship, and cross-functional collaboration.

Qualifications
The ideal candidate will hold current, active licensure in one of the following: registered nurse (RN), licensed practical nurse (LPN), respiratory therapist (RT), licensed clinical social worker (LCSW), licensed professional counselor (LPC), licensed marriage and family therapist (LMFT), licensed psychologist, or an equivalent credential. For behavioral health-focused roles, a Certified Alcohol and Drug Counselor (CADC) I or higher is required—or must be obtained within the first 12 months of employment.

A minimum of three years of clinical experience in medical, behavioral health, or integrated healthcare settings is required, including direct support for individuals with complex needs. Candidates must demonstrate exceptional written and verbal communication skills, with the ability to present complex clinical information clearly to both clinical and non-clinical audiences.

Technological fluency is essential, including proficiency in Microsoft Office, virtual communication tools, and the ability to navigate complex data systems and electronic medical records. The successful candidate will be highly organized, capable of independently managing a dynamic caseload, and committed to timeliness, accuracy, and compliance. Candidates must also be in good standing with all applicable regulatory boards and not suspended, excluded, or debarred from participation in federal healthcare programs such as Medicare or Medicaid.

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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