CARE MANAGEMENT UTILIZATION REVIEW SPECIALIST

Who You’ll Join

At Santiam Hospital & Clinics, we believe exceptional patient care starts with a supportive and inclusive work environment. We empower every team member by providing access to advanced medical technology and continuous professional development. Join our collaborative culture, where your contributions are valued and your growth is encouraged.   

Come join our Utilization Management team as our new Utilization Management Specialist where you will play a critical role in ensuring patients receive the right care at the right time. Using clinical expertise and strong payer collaboration, this role drives timely authorizations, supports medical necessity decisions, and ensures compliance with CMS and payer guidelines. It’s an ideal opportunity for detail driven professionals who want to influence quality outcomes and support providers, while making a meaningful impact across the continuum of care. 

Take the next step in your healthcare career—apply today and bring your expertise to Santiam Hospital & Clinics, recently honored as 2025’s Best Hospital in the Willamette Valley! 

Position Schedule: Monday – Friday, 8:00 am – 12:00 pmSalary range: $22.50 - $33.04 

What You’ll Do: 

• Performs clinical chart reviews for appropriate admissions, continued stays, and supportive services to promote quality care and full and accurate capture of revenue. 

• Ensure compliance with CMS, state, and payer-specific utilization review requirements 

• Submit and monitor payer notifications for admissions, continued stay, and changes in status 

• Follow authorizations from initial notification through approval and additional authorized days, including entering and monitoring approved bed days in UM navigator 

• Proactively engaged in obtaining auth approvals and continued follow-up as needed for approval/denials 

• Communicates with insurance companies regarding the medical necessity of admissions and provides clinical documentation and reviews as requested for purposes of ongoing authorization of hospital stays. 

• Communicate discharge information and clinical updates to payers as required daily. 

• Communicate with the attending physician or nursing staff, when needed, to address the appropriate level of care, and order changes. 

• Collaborate with CML and UM staff to deliver appropriate Medicare forms to patients when required (e.g., Code 44, Code W2, and Hospital Issued Notices of Non-Coverage). 

• Keeps Patient Registration and Patient Financial Services informed of any changes in admission status, working toward accurate capture of admission status prior to initial billing. 

• Continually assesses clinical services for appropriateness for continued stay. 

• Serves as a resource and actively provides education for physicians related to Medicare and third-party payor billing requirements, correct admission status, and documentation supporting medical necessity. 

• Participates in the Utilization Review Committee. 

• Assists UM RN Lead in medical necessity denial and appeals processes, ensuring prompt and accurate follow-up to ensure resolution and timely billing. 

• Documents actions taken in the patient financial record and clinical review in UM navigator.