Utilization Review Nurse

UTILIZATION REVIEW NURSE

REMOTE Ability to travel on-site to 3031 NE STEPHENS ST., ROSEBURG OR, 97470, as needed for business operations. EMPLOYMENT TYPE: Full-Time, Exempt About Umpqua Health At Umpqua Health, we're more than a healthcare organization-we're a community-driven Coordinated Care Organization (CCO) dedicated to improving the health and well-being of individuals and families throughout Douglas County, Oregon. We provide integrated, whole-person care through primary care, specialty care, behavioral health services, and care coordination. Our collaborative approach ensures members receive high-quality, personalized care while supporting a stronger, healthier community. POSITION PURPOSE The Utilization Management Nurse evaluates 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 safe transitions across care settings, ensuring compliance with Oregon Health Plan (OHP), Medicare, and applicable regulations. The UM Nurse collaborates with interdisciplinary teams and community providers to promote integrated, high-quality care. ESSENTIAL JOB RESPONSIBILITIES Perform clinical assessments and prior authorizations to determine medical necessity Escalate complex cases to Medical Directors and request additional documentation as needed Collaborate with care coordinators, discharge planners, and interdisciplinary teams for care transitions Liaise with internal departments to resolve eligibility, benefits, or service issues Participate in discharge planning for members transitioning from acute, long-term, or residential care Conduct audits and support quality improvement initiatives Provide training and mentorship on UM protocols and workflows Maintain relationships with community providers and service organizations Ensure compliance with organizational policies, clinical standards, and federal/state regulations 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. 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 Proficiency with Microsoft Office, EHR systems, and UM software Strong clinical knowledge, communication, and organizational skills No suspension, exclusion, or debarment from federal healthcare programs PREFERRED QUALIFICATIONS 2+ years of utilization review or case management experience in managed care Oregon residency and license Bilingual or translation skills a plus Experience with quality improvement audits and diverse team collaboration Ability to work independently in fast-paced environments SCHEDULE Monday through Friday - 8:00am - 5:00pm; standard business hours with flexibility to meet service timelines. SALARY Wage Band: $85,000- $105,340 BENEFITS Salary is dependent on skills, experience, and education Generous benefits package including vacation PTO, sick leave, federal holidays, and birthday leave Medical, dental, and vision insurance 401(k) with company match (fully vested immediately) Company-sponsored life insurance and additional benefits Fitness reimbursement program Tuition reimbursement and more Why Umpqua Health? We are committed to advancing health equity by collaborating across communities, addressing systemic barriers, and ensuring fair access to care and resources. At Umpqua Health, every team member plays a vital role in making a meaningful impact, empowering healthier lives and strengthening the communities we serve. Inclusive Culture We foster a respectful, inclusive environment where employees feel valued, supported, and empowered. Growth & Development We support ongoing learning through mentorship, clear career pathways, and professional development opportunities. Work/Life Balance We promote flexibility and well-being so employees can thrive both professionally and personally. Equal Opportunity 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. Umpqua Health