Utilization Review Nurse, OR

POSITION PURPOSE 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. ESSENTIAL JOB RESPONSIBILITIES • 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. QUALIFICATIONS Minimum Qualifications • Licensure: Active, unrestricted Registered Nurse (RN), BSN (Bachelor of Science in Nursing, MSN (Master of Science in Nursing) license in the state of Oregon or a compact state. • Education: Graduation from an accredited nursing program. • Experience: Minimum of five (5) years of direct patient care experience in a clinical setting, such as a medical office, hospital, or long-term care facility. Core Competencies & Skills • Clinical Nursing Expertise: Deep understanding of medical terminology, diagnoses, procedures, and care modalities. Experienced in interpreting clinical documentation and applying nursing knowledge to support utilization review and care decisions. • Utilization Management: Proficient in InterQual criteria, UM software, and evidence-based guidelines. Skilled in reviewing requests for medical services and ensuring appropriate use of resources. • Regulatory Compliance: Strong working knowledge of NCQA standards, Oregon Health Plan (OHP), and Coordinated Care Organization (CCO) regulations, including OAR, ORS, CFR, CMS, DMAP, and the Prioritized List of Health Services. • Medical Coding & Insurance: Familiar with ICD and CPT codes, health insurance processes, and state-mandated benefits. • Technology & Documentation: Proficient in Microsoft Office (Word, Excel, Outlook), EHR systems, and managed care platforms. Accurate typing at 45+ WPM. • Communication & Collaboration: Excellent interpersonal, written, and verbal communication skills. Builds strong relationships with providers, community services, and internal teams. • Organization & Problem Solving: Highly organized and detail-oriented. Capable of managing multiple priorities, analyzing complex situations, and developing effective solutions. • Ethical Standards: Maintains compliance with federal healthcare program requirements. No suspension, exclusion, or debarment from Medicare/Medicaid. Preferred Qualifications • Two (2) years of utilization review or case management experience in a managed care organization or commercial insurance. • Oregon residency and Oregon nursing license. • Proficient in electronic systems for data entry and retrieval. • Strong critical thinking, time management, and organizational skills to meet goals and deadlines. • Demonstrated ability to work independently and collaboratively in fast-paced environments. • Committed to continuous learning and expanding responsibilities. • Knowledgeable in contractual benefits and alternative coverage options. • Maintains patient confidentiality and secure health record practices. • Current clinical certification and up-to-date knowledge base. • Capable of conducting quality improvement audits and reporting findings. • Effective in managing multiple priorities with attention to detail and accuracy. • Experience working on diverse teams and considering equity impacts in decision-making. • Bilingual capabilities or translation experience is 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. Apply tot his job