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Utilization Review Nurse This position has a remote option for those living close and will be able to come into the hospital as needed. The Utilization Review Nurse is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services "CMS" Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and guidelines related to UM. This nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS. Responsibilities: • Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders. • The prior authorization role completes an assessment of a proposed service to determine if the beneficiary has eligible coverage for the service and if it is medically necessary. • Promote quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence-based clinical guidelines. • Identify and present cases of possible quality of care deviations, questionable admissions, and prolonged lengths of stay to the Medical Director for further determination. • Appropriately refer beneficiaries who have complex or chronic conditions, a need for transition of care, disease management support, or other identifiable needs for coordination of the beneficiary's member's health care for behavioral health care management. • Follow CHRISTUS Health Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI). • Protect the confidentiality of data and intellectual property; assures compliance with national health information guidelines. • Analyze clinical information submitted by medical providers to evaluate the medical necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities. • Perform provider outreach to address post-hospital discharge services, redirection to in-network providers for appropriate steerage, durable equipment usage, and utilization of other medical services and/or procedures and other necessary telephonic follow-up. • Utilize the nursing process and critical thinking skills to provide oversight of services and evaluation of service options. • Ability to work in a variety of settings with culturally diverse communities with the ability to be culturally sensitive and appropriate. • Must have excellent communication skills (written and verbal), clinical judgment, initiative, critical thinking, and problem-solving abilities. • Must be able to take after hour calls to meet business requirements as needed. Job Requirements: Education/Skills • Graduate of an accredited school of vocational nursing or equivalent required • Associate's (ADN) or Bachelor's (BSN) in Nursing preferred Experience • 3 – 5 years of nursing experience preferred • Experience in Microsoft software (e.g., Outlook, Teams, Word, and Excel) required • General computer knowledge and capability to use computers required Licenses, Registrations, or Certifications • LVN license in the state of employment or compact required • RN license in state of employment or compact preferred Work Schedule: 5 Days - 8 Hours Work Type: Full Time

UTILIZATION REVIEW NURSE REMOTE Ability to travel on-site to 3031 NE STEPHENS ST., ROSEBURG OR, 97457, as needed for business operations. 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 Management Nurse evaluates clinical service requests to ensure medically necessary, cost-effective, and evidence-based care for members. This role conducts prior authorizations, facilitates care coordination, and supports safe transitions across care settings, ensuring compliance with Oregon Health Plan (OHP), Medicare, and applicable regulations. The UM Nurse collaborates with interdisciplinary teams and community providers to promote integrated, high-quality care. ESSENTIAL JOB RESPONSIBILITIES • Perform clinical assessments and prior authorizations to determine medical necessity • Escalate complex cases to Medical Directors and request additional documentation as needed • Collaborate with care coordinators, discharge planners, and interdisciplinary teams for care transitions • Liaise with internal departments to resolve eligibility, benefits, or service issues • Participate in discharge planning for members transitioning from acute, long-term, or residential care • Conduct audits and support quality improvement initiatives • Provide training and mentorship on UM protocols and workflows • Maintain relationships with community providers and service organizations • Ensure compliance with organizational policies, clinical standards, and federal/state regulations • Perform other nursing-related duties as assigned CHALLENGES • Working with a variety of personalities, maintaining a consistent and fair communication style. • Satisfying the needs of a fast-paced and challenging company. MINIMUM QUALIFICATIONS • Active, unrestricted RN license (BSN or MSN) in Oregon or a compact state • Graduation from an accredited nursing program • Minimum 5 years of direct patient care experience • Proficiency with Microsoft Office, EHR systems, and UM software • Strong clinical knowledge, communication, and organizational skills • No suspension, exclusion, or debarment from federal healthcare programs PREFERRED QUALIFICATIONS • 2+ years of utilization review or case management experience in managed care • Oregon residency and license • Bilingual or translation skills a plus • Experience with quality improvement audits and diverse team collaboration • Ability to work independently in fast-paced environments SCHEDULE Monday through Friday - 8:00am - 5:00pm; standard business hours with flexibility to meet service timelines. SALARY Wage Band: $85,000- $105,340 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.