Providence Health & Services Beaverton , OR 97075
Posted 6 days ago
Providence Health Plan caregivers are not simply valued - they're invaluable. Join our team and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.
Providence Health Plan is calling an Associate Utilization Review Specialist who will:
Be responsible for all core functions in one or more of the following clinical teams:
Prior-authorization (PA)
Concurrent Review (CCR)
SNF
Clinical Claims
Coordinate and execute the medical review and research functions required to support all teams listed above
Investigate, review, and prepare all requests for coverage for all lines of business (LOB) in multiple applications (Facets, CIM, CareAdvance, Workforce, internal OneNote workflows, etc.) while using multiple resources to support the review (Medical Policies, KMS, Benefit Grids, Handbooks, CES/JAMA coding configuration, etc.)
Critically assess and prepare all cases for RN/MD review of coverage (medical necessity, eligibility, network status, regulatory)
Uses 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. Authorizes payment of select medical services
Provide research, assessment, and proposed resolution of operational issues as they relate to coverage policy, correct coding (CP/HCSPCS, Dx., DRG), regulations, and other coverage rules
Take incoming phone calls from providers and members regarding clinical operational plan functions with an ability to research and follow-up on unique medical and coding requests and plan processes for all lines of business
Responsible for ensuring service review requests and clinical 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 (medical and coding review requests, call centers, research briefs, provider resolutions)
Providence welcome 100% remote work for residents who reside in the following States:
Oregon
Washington
California
Required qualifications for this position include:
Preferred qualifications for this position include:
Why Join Providence?
Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.
Providence Health & Services