Utilization Review Clinician

Utilization Review Clinician Remote

Ability to travel on-site to 3031 NE STEPHENS ST. ROSEBURG, OR 97470, as needed for business operations

Employment Type:

Full-Time, Exempt

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.

The Utilization Review Clinician (URC) performs a clinical review and assesses care related to mental health and substance abuse. Monitors and determines if level of care and services related to mental health and substance abuse are medically appropriate.

• Evaluate behavioral health and substance use disorder services to determine medical necessity, level of care, benefit eligibility, and compliance with established clinical guidelines.
• Review behavioral health, Health-Related Social Needs (HRSN), and Flexible Services requests for appropriateness and coverage determination.
• Conduct prospective, concurrent, and retrospective reviews, including inpatient behavioral health reviews, discharge planning, and transitions of care.
• Apply clinical judgment and evidence-based criteria to make utilization decisions and identify cases requiring Medical Director review.
• Request and evaluate additional clinical information from providers and members to support timely and accurate determinations.
• Complete appeal reviews in collaboration with the Grievance and Appeals team.

• Collaborate with care management teams, providers, and internal departments to support integrated behavioral and physical healthcare services.
• Advocate for members by promoting access to timely, effective care in the least restrictive and most appropriate setting.
• Support transitions from inpatient, residential, acute care, and Oregon State Hospital settings to community-based services.
• Identify barriers to care and support solutions that promote continuity of services and improved outcomes.

• Partner with behavioral health providers and healthcare teams regarding treatment plans, level of care, and utilization management processes.
• Provide education and guidance to providers, members, and families regarding behavioral health benefits, services, and available resources.
• Develop and maintain effective relationships with community providers and organizations.

• Maintain compliance with Umpqua Health policies, contractual requirements, and applicable state and federal regulations, including Oregon Administrative Rules (OAR), Oregon Health Plan (OHP), Medicare guidelines, and grievance and appeal requirements.
• Maintain accurate, timely, and comprehensive clinical documentation in accordance with regulatory and organizational standards.
• Conduct quality reviews and audits to identify opportunities for process improvement.
• Meet departmental expectations for productivity, accuracy, quality, and turnaround times.

• Collaborate with Third-Party Recovery and Customer Care teams regarding coverage, eligibility, and coordination of benefits.
• Participate in clinical rounds, case reviews, and interdisciplinary discussions.
• Provide training and support to new employees and cross-functional teams as needed.
• Perform other duties and responsibilities as assigned.

• Working with a variety of personalities, maintaining a consistent and fair communication style.
• Satisfying the needs of a fast-paced and challenging company.

• Current Oregon license to practice independently as one of the following:
• Licensed Clinical Social Worker (LCSW)
• Licensed Professional Counselor (LPC)
• Licensed Marriage and Family Therapist (LMFT)
• Registered Nurse (RN) with Behavioral Health certification…