Associate Utilization Review Specialist - Remote

Associate Utilization Review Specialist – Remote

• Be responsible for all core functions in the Prior Authorization (PA) Department
• Coordinate and execute the review and research functions required to support the PA Department
• Investigate, review, and prepare all requests for prior authorization review for all lines of business (LOB) in multiple applications (Facets, CIM, Care Advance, etc.) while using multiple resources to support the review (Medical Policies, KMS, Benefit Grids, Handbooks, etc.)
• Critically assess and prepare all cases for RN/MD review of coverage (medical necessity, eligibility, network status, regulatory)
• Use appropriate resources and sound judgement to review and approve specific service requests based on deep understanding of medical service requested, CPT/HCPCS codes, and plan design. Authorize select medical services
• Provide research, assessment, and proposed resolution of operational issues as they relate to coverage policy, correct coding (CPT/HCPCS, Dx), regulations, and other coverage rules
• Take incoming phone calls from providers and members regarding operational plan functions with ability to research and follow‑up on unique prior authorization related requests and plan processes for all lines of business
• Ensure service review requests and inquiries are complete and adjudicated to meet regulatory and compliance requirements, including timeliness
• Consult or triage to appropriate subject matter experts internally and across departments
• Work in a fast‑paced environment with strict compliance and turn‑around times for all work metrics (prior authorization requests, customer service inquiries, provider resolutions, etc.)

• Bachelor’s Degree in Health related field, or applicable 2 years work experience may be substituted for some education.
• 2 years experience in healthcare related field (or equivalent education)
• 1 year experience and proven track record of researching and resolving complex problems which required critical thinking
• 2 years experience in fast‑paced working environment with a proven record of successful ability to quickly prioritize and resolve issues to meet timeliness and quality metrics.
• 1 year experience in database management and spreadsheets.
• 6 months experience with telephony systems, call center phone volumes and multi‑line communication systems.

• 3 years experience in healthcare related field (or equivalent education)

• Oregon
• Washington
• California

• California:
  Humboldt – Min: $29.62, Max: $45.31
• California:
  All Northern California – Except Humboldt – Min: $33.23, Max: $50.84
• California:
  All Southern California – Except Bakersfield – Min: $29.62, Max: $45.31
• California:
  Bakersfield – Min: $28.41, Max: $43.47
• Oregon:
  Non‑Portland Service Area – Min: $26.49, Max: $40.52
• Oregon:
  Portland Service Area – Min: $28.41, Max: $43.47
• Washington:
  Western – Min: $29.62, Max: $45.31
• Washington:
  Southwest – Olympia, Centralia & Below – Min: $28.41, Max: $43.47
• Washington:
  Eastern – Min: $25.28, Max: $38.68
• Washington:
  South Eastern – Min: $26.49, Max: $40.52

Providence Health Plan offers a comprehensive benefits package including a retirement 401(k) savings plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well‑being resources and much more. Learn more at (Use the "Apply for this Job" box below)..

Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement.