Associate Utilization Review Specialist *Remote*

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
  • Provider Reconsideration
  • Member Appeals
  • Medical
  • Coding
  • Reimbursement Policy
• 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 such as:
  • Facets
  • CIM
  • CareAdvance
  • Workforce
  • Internal OneNote workflows
• Utilize multiple resources to support the review such as:
  • Medical Policies
  • KMS
  • Benefit Grids
  • Handbooks
  • CES/JAMA coding configuration
• 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)

We welcome 100% remote work for residents who reside in the following state:

• Oregon
• Washington

Required qualifications for this position include:

• Bachelor's Degree in a Health related field of study -OR- a combination of equivalent education and experience
• 2+ years' experience in healthcare related field
• 1+ years' experience researching and resolving complex problems that require critical thinking
• 2+ years' experience working in a fast-paced environment
• 2+ years' experience prioritizing and resolving issues to meet timelines and quality metrics
• 1+ years' experience working with database management and spreadsheets
• 6+ months experience working with phone systems, call center phone volumes and multi-line communication systems

Preferred qualifications for this position include:

• 3+ years' experience in a healthcare related field

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.

The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

Check out our benefits page for more information about our Benefits and Rewards.