Title: Utilization Review Specialist Location: Roseburg, OR Full Time Department: Utilization Management Job Description: Utilization Review Specialist HYBRID, must be able to travel to 3031 NE STEPHENS ST. ROSEBURG, OR 97470 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 Review Specialist supports Umpqua Health Alliance by coordinating the intake, review, processing, and completion of prior authorization requests within Medical Management. This role is responsible for ensuring accurate and timely handling of authorizations, maintaining compliance with regulatory and organizational requirements, supporting communication with providers and members, and assisting with workflow coordination to promote efficient utilization management operations. ESSENTIAL JOB RESPONSIBILITIES - 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. CHALLENGES - 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 MINIMUM QUALIFICATIONS - High school diploma or equivalent. - Proficient computer skills, including Microsoft Office Suite (Word, Excel, Outlook, Teams), data entry, and internet research. - Experience using standard office equipment and systems, including keyboarding, web-based phone systems, and cloud-based document storage. - Ability to type a minimum of 45 words per minute with a high degree of accuracy. - Strong attention to detail. - No suspension, exclusion, or debarment from participation in federal healthcare programs (e.g., Medicare/Medicaid) PREFERRED QUALIFICATIONS - 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 SCHEDULE Monday through Friday - 8:00am - 5:00pm; standard business hours with flexibility to meet service timelines. SALARY Wage Band : $41,600- $47,000 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.

Role Description The Clinical Documentation Integrity Specialist focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. This role involves: - Performing concurrent chart reviews to validate that clinical documentation appropriately describes the patient’s severity of illness, complexity of care, and risk of mortality. - Utilizing advanced knowledge of disease processes and medications to analyze documentation and identify gaps. - Facilitating modifications to documentation through interactions and collaborations with providers, coding, quality, and case management teams. - Serving as a resource and educator for providers and interdisciplinary care teams. Qualifications - Minimum of 3 years of experience in inpatient clinical documentation improvement role required. - Minimum of 5 years of nursing experience in adult acute care (med/surg, critical care, emergency, or PACU) required. - Certification minimum requirement – RN, CCDS and/or CDIP. - Current state Registered Nursing license required. - Coding credential highly preferred (CCS, CPC, CCS-P). - Clinic fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems. - Demonstrated skills in analytical thinking and problem solving. - Excellent communication and people skills. - Self-motivated and able to work independently without close supervision. - Proficient in the use of computers including Microsoft Office (Word, Excel, PowerPoint, etc.), Outlook, and other applications necessary for the CDS role. Requirements - Analyzes medical records to identify incomplete or inaccurate documentation related to diagnoses, treatments, and procedures. - Periodically analyzes coding data to identify documentation variations and determine the cause and appropriateness of such variation; presents findings to management. - Works closely with healthcare professionals to clarify and obtain additional information needed for accurate documentation. - Facilitates modification to clinical documentation supporting the clinical picture/level of severity rendered to all patients. - Collaborates with stakeholders to clarify and improve documentation. - Provides support to medical coders by ensuring documentation supports assigned codes and compliance with coding guidelines. - Communicates effectively with coding teams to address coding-related issues. - Conducts training sessions for healthcare staff on proper documentation practices, coding guidelines, and compliance requirements. - Utilizes data analytics to identify trends, patterns, and areas for improvement in documentation accuracy and completeness. - Monitors daily DRG assignment and reports to track performance improvement. - Demonstrates understanding of current Quality Measure Initiatives including Value Based Purchasing, Pay for Performance, and Readmission criteria. - Ensures documentation aligns with regulatory requirements, coding standards, and healthcare policies. - Conducts regular audits to assess the quality of clinical documentation. - Participates in quality improvement initiatives related to clinical documentation and coding accuracy. - Uses, protects, and discloses patients’ protected health information (PHI) in accordance with HIPAA standards. - Limits viewing of PHI to the absolute minimum necessary to perform assigned duties. - Understands and complies with Information Security and HIPAA policies and procedures at all times. Company Description Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, or any other characteristic protected by federal, state or local law.

• Provides clinical based review and analysis of the documentation in the patient’s medical record • Collaborates with physician, mid-level providers, ancillary staff, and medical records coders • Conducts initial and ongoing concurrent and some retrospective reviews for system wide admissions for all payors • Identifies when there is a need to clarify documentation in patient records • Supports Lean principles of continuous improvement

Role Description - Manages assignments and projects as assigned. - Participates in the daily operations and activities of the Clinical Documentation Improvement (CDI) program to continually enhance documentation. - Utilizes most current documentation tools available. - Regularly and effectively communicates with clinical staff. - Collaborates with coding in an effort to maintain coding and documentation quality and compliance. Ensures that coding process and guidelines meet State and Federal requirements and standards. - Works with the medical staff to continuously improve clinical documentation to facilitate accurate coding through the use of compliant physician queries, when appropriate. - Facilitates communication of various professionals to support organizational goals related to documentation integrity, compliance, quality and coding. - Assists in development and delivery of education for both clinical and non-clinical staff. - Meets performance standards by setting goals and objectives, prioritizing work, and using available resources efficiently and effectively. - Stays abreast of the latest developments, advancements, and trends in the field of documentation improvement and coding by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and maintaining certification or licensure. Integrates knowledge gained into current work practices. - Participates in the training of new employees as needed. - Ensures that work is completed accurately and according to schedule. Qualifications - Current registered nurse (RN) license with a Bachelor's Degree in Nursing plus 2 years of experience in acute care, health care administration or commensurate experience. - Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) credential must be obtained within one year of hire. - Experience with ICD-10-CM/PCS coding and DRG assignment. - Outstanding oral, written and interpersonal skills. - Demonstrated knowledge and clinical experience relevant to clinical and regulatory aspects of care and reimbursement. Preferred Qualifications - CCDS or CDIP upon hire plus 2 years of clinical documentation improvement experience.