Utilization Review Specialist

Support Utilization Review activities related to the prior authorization process.  

Manage intake, tracking, and routing of prior authorization requests and supporting documentation.  

Review requests for completeness and ensure appropriate routing for processing.  

Communicate with healthcare providers to obtain additional information and resolve documentation issues.  

Track prior authorization requests using established systems to ensure timely processing.  

Support timely notification of prior authorization determinations.  

Coordinate daily workflow and telephone coverage with team members.  

Respond to internal and external inquiries regarding prior authorizations and route as appropriate.  

Monitor and report on turnaround times to ensure compliance with requirements.  

Maintain knowledge of applicable regulations, policies, and procedures.  

Comply with organizational policies and applicable to federal, state, and local regulations. 

Strong organizational skills with the ability to stay organized and productive in a remote, independent work environment  

Proactive communication with internal and external stakeholders  

Consistent ability to meet Oregon Health Plan (OHA) timeline and turnaround requirements  

Ability to manage shifting priorities in a fast-paced environment  

Ability to coordinate tasks and resources to meet operational goals and objectives 

1+ years of experience in healthcare, managed care, medical coding, claims processing, or a related field 

Knowledge of medical terminology, procedure codes, and diagnosis codes  

Familiarity with Oregon Health Plan (OHP) and Coordinated Care Organizations (CCO), including applicable regulations (OAR, ORS, CFR, CMS, DMAP)  

Strong organizational skills with the ability to manage multiple priorities in a fast-paced environment  

Ability to meet deadlines while maintaining accuracy and attention to detail  

Strong communication and customer service skills (written, verbal, and interpersonal)  

Ability to work independently and collaboratively with sound judgment and confidentiality  

Strong critical thinking and time management skills  

Self-motivated with ability to follow policies, procedures, and workflows in a remote environment  

Flexible and adaptable in a changing work environment  

Willingness to learn and take on additional responsibilities as needed  

Ability to work a standard schedule: Monday–Friday, 8:00 AM–5:00 PM PST  

Experience working in diverse teams and with varied communication styles  

Experience considering the impact of work on diverse communities, including communities of color  

Bilingual or translation skills preferred