Utilization Specialist – REMOTE (in OR or WA) Job Vacancy in Umpqua Health Roseburg, OR 97470 – Latest Jobs in Roseburg, OR 97470

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Company Name : Umpqua Health
Location : Roseburg, OR 97470
Position : Utilization Specialist – REMOTE (in OR or WA)

Job Description : POSITION PURPOSEThe Utilization Review Specialist provides support to Umpqua Health Alliance (UHA) for the intake and processing of requests received by Clinical Engagement in compliance with regulatory requirements.*ESSENTIAL JOB RESPONSIBILITIES**Provide support for Utilization Review and Care Coordination as related to the prior authorization process.Manage the receipt of documentation through multiple sources on a daily basis including appeals, grievances and prior authorizations.Identify incoming documentation requests and redistribute to appropriate individual(s) for processing.Tracks and sorts prior authorization requests and supporting information using current systems and processes.Support the timely notification of prior authorization determinations.Coordinate with other Utilization Review Specialists for daily management of department telephone coverage with individual login and availability.Research and respond to requests from internal and external customers regarding prior authorizations. Refer members and providers to other appropriate staff as necessary.Provide support to the Appeals & Grievances Coordinator as needed.Participate in department trainings, audits, and meetings as needed.Maintain a solid understanding of regulations and procedures.Review daily reports to monitor compliance.Maintain training documents and participate in updates for policies and procedures.Provide support for internal and external reporting.Train new and cross departmental staff as well as assist leadership with onboarding procedures.Conduct audits and other investigatory activities to identify and rectify process improvement opportunities.Work collaboratively with claims and provider networking department to problem solve and communicate with internal and external stakeholder of changes or improvements in processes. This include developing educational materials to be managed on the UHA website, provider newsletter, talking points and department trainings.Assist manager and director with administrative support tasks, such as meetings, employee engagement opportunities and communications.Ability to create and analyze reports using Microsoft Excel.Comply with organization’s internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations.Complexity of duties may vary based on the level of experience, education and qualifications of specialist.Other duties as assigned.*GUIDING BEHAVIORS**Accountability*Always demonstrate the highest performance and behavior standards. Share responsibility and expect others to be accountable.*Efficiency*Demonstrate a proactive approach to problem identification and solutions. Be innovative and solutions oriented, improving processes while reducing costs. Demonstrate appropriate time-management skills. Optimize the use of available resources.*Be a Team Player*Support and assist your team members. Be available to help and learn from your team. Keep an open mind to feedback and earn trust of staff.*Integrity*Keep your promises, commitments, and confidences. Be honest and straightforward dealing with all issues fairly and consistently.*Stewardship*Adhere to all state and federal regulations relating to your position including the Health Insurance Portability and Accountability Act (HIPAA), Fraud & Abuse and Occupational Safety and Health Administration (OSHA) laws. Abide by Company policies and procedures at all times.*CHALLENGES**Interaction with a variety of personalities.Working in a fast-paced environment with shifting priorities.Coordinating resources to achieve goals and objectives.Remote/work from home: Must have a separate room with a locked door that can be used as a home office to ensure you and your patients have absolute and continuous privacy while you work.Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10×1 (10mbs download x 1mbs upload) is required.*QUALIFICATIONS**Minimum 3 years’ experience in utilization or related field.Must have experience in Managed Care Organization.Experience in medical coding and/or billing or claims preferred.Must have knowledge and understanding of the laws, regulations and policies, including, but not limited to, the OAR’s, CFR’s, ORS’s that govern the Oregon Health Plan as well as all applicable Medicare guidelines. It also includes the policies and procedures that apply to the appeal and grievance process, prior authorizations, covered services and the member’s rights and responsibilities as stated by the Division of Medical Assistance Program (DMAP) as well as CMS.Proficient understanding of medical terminology required.High school diploma or equivalent.CNA, MA with some medical background preferred.Excellent interpersonal, written and oral communication skills.Prior experience in a customer service and/or clinical setting.Knowledge of medical terminology, procedure codes and diagnosis codes.Proficiency with MS Office applications such as; Office, Outlook and Excel.Proficiency with basic office equipment skills such as computer keyboarding, copy machines, multiline phone systems, etc.Ability to type at least 45 wpm with a high degree of accuracy.Ability to manage multiple priorities with attention to detail and follow-up.Ability to organize work and remain focused under stressful conditions with critical attention to detail for accuracy and timeliness.Ability to work effectively with a team, other departments, and exercise sound judgment in handling assigned tasks including maintenance of strict confidentiality.Ability to interact effectively and professionally with internal and external customers.*PHYSICAL DEMANDS*Typical office environment requiring standing, sitting, walking, bending, and lifting up to 25 pounds.Job Type: Full-time

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