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Medical Utilization Review Jobs in Oregon (NOW HIRING)

Umpqua Health

Utilization Review Specialist

Winston, OR · On-site

$41K - $47K/yr

POSITION PURPOSE The Utilization Review Specialist supports Umpqua Health Alliance by coordinating the intake, review, processing, and completion of prior authorization requests within Medical ...

Umpqua Health

Utilization Review Nurse

Roseburg, OR · On-site +1

$85K - $105K/yr

UTILIZATION REVIEW NURSE REMOTE Ability to travel on-site to 3031 NE STEPHENS ST., ROSEBURG OR ... Escalate complex cases to Medical Directors and request additional documentation as needed

Providence Service

Utilization Review RN

Portland, OR · On-site

Five (5) years Clinical experience in an acute adult medical/surgical care setting, OR Five (5) years Current Utilization Review or Case Management experience. * Demonstrated clinical expertise and ...

New

St. Charles Health System

RN Utilization Review

Bend, OR · On-site

$48.30 - $72.45/hr

Manager- Utilization Management DEPARTMENT: Utilization Management DATE LAST REVIEWED: November ... Completes Observation medical necessity reviews at a minimum of every 12 hours (twice daily)

Stcharles

RN Utilization Review

Bend, OR

$48.30 - $72.45/hr

Manager- Utilization Management DEPARTMENT: Utilization Management DATE LAST REVIEWED: November ... Completes Observation medical necessity reviews at a minimum of every 12 hours (twice daily)

St. Charles Health System

RN Utilization Review

Bend, OR · On-site

$48.30 - $72.45/hr

Manager- Utilization Management DEPARTMENT: Utilization Management DATE LAST REVIEWED: November ... Completes Observation medical necessity reviews at a minimum of every 12 hours (twice daily)

Umpqua Health

Utilization Review Clinician

Roseburg, OR · On-site +1

$80K - $94K/yr

UTILIZATION REVIEW CLINICIAN REMOTE Ability to travel on-site to 3031 NE STEPHENS ST. ROSEBURG, OR ... Evaluate behavioral health and substance use disorder services to determine medical necessity ...

P3 Health Partners

Concurrent Review RN

Salem, OR · On-site

$90K - $100K/yr

In-depth understanding of utilization management principles and medical necessity review processes ... Experience applying evidence-based criteria, including InterQual, MCG, and CMS guidelines.

New

P3 Health Partners

Concurrent Review RN

Salem, OR · On-site

$90K - $100K/yr

In-depth understanding of utilization management principles and medical necessity review processes ... Experience applying evidence-based criteria, including InterQual, MCG, and CMS guidelines.

New

P3 Health Partners

Concurrent Review RN

Salem, OR

$90K - $100K/yr

In-depth understanding of utilization management principles and medical necessity review processes ... Experience applying evidence-based criteria, including InterQual, MCG, and CMS guidelines.

New

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Medical Utilization Review information

See Oregon salary details

$22

$44

$72

How much do medical utilization review jobs pay per hour?

As of Aug 14, 2026, the average hourly pay for medical utilization review in Oregon is $44.70, according to ZipRecruiter salary data. Most workers in this role earn between $35.34 and $51.35 per hour, depending on experience, location, and employer.

What are the key skills and qualifications needed to thrive as a medical utilization review specialist, and why are they important?

To thrive as a Medical Utilization Review Specialist, you need a background in healthcare (often as an RN or LPN), strong analytical abilities, and in-depth knowledge of medical terminology and insurance guidelines. Familiarity with utilization management software, electronic health records (EHRs), and certifications such as Certified Professional in Healthcare Quality (CPHQ) are commonly required. Excellent communication, critical thinking, and attention to detail are vital soft skills for effectively reviewing cases and collaborating with providers. These competencies ensure accurate, efficient decision-making that supports both patient care standards and cost-effective healthcare delivery.

Is medical utilization review a stressful job?

Medical utilization review can be stressful due to the need to evaluate complex medical cases, meet strict deadlines, and ensure accurate decisions. The job often requires attention to detail, critical thinking, and sometimes handling difficult interactions with providers or patients. However, stress levels vary depending on workload, work environment, and individual coping skills.

What are some common challenges faced by professionals in medical utilization review, and how can they be addressed?

Professionals in Medical Utilization Review often encounter challenges such as managing high caseloads, staying updated with changing healthcare regulations, and balancing the needs of patients with cost-containment measures. Effective time management and ongoing education in current medical guidelines can help address these issues. Additionally, strong communication skills are essential for collaborating with healthcare providers and insurance companies to ensure appropriate care decisions while maintaining compliance.

How do I get into a medical utilization review?

To become a medical utilization review specialist, candidates typically need a healthcare background such as nursing, medical assisting, or health administration, along with knowledge of insurance policies and medical coding. Certification programs like the Certified Professional Medical Auditor (CPMA) or Certified Medical Reimbursement Specialist (CMRS) can enhance job prospects. Relevant skills include attention to detail, analytical thinking, and familiarity with medical records and billing systems.

What does a medical utilization review specialist do in healthcare?

A medical utilization review specialist evaluates healthcare services to determine their necessity, efficiency, and appropriateness based on established guidelines. They review patient records, collaborate with healthcare providers, and ensure compliance with insurance policies, often using specialized software. This role helps control healthcare costs and ensures quality patient care.

What is the difference between Medical Utilization Review vs Medical Claims Reviewer?

AspectMedical Utilization ReviewMedical Claims Reviewer
CredentialsCertifications like CCM, RHIA, or RHIT often preferredCertifications such as CPC or CCS beneficial
Work EnvironmentHealthcare facilities, insurance companies, or third-party review organizationsInsurance companies, healthcare payers, or claims processing centers
Primary FocusAssessing necessity and appropriateness of medical servicesReviewing and processing insurance claims for payment
Industry UsageCommonly used in healthcare and insurance sectorsPrimarily in insurance and healthcare billing sectors

Medical Utilization Review focuses on evaluating the necessity of medical services, while Medical Claims Review centers on processing insurance claims. Both roles require healthcare knowledge and certifications, but they serve different functions within the healthcare and insurance industries.

What is medical utilization review?

Medical utilization review is a process used by healthcare organizations and insurance companies to evaluate the necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities. The goal is to ensure that patients receive necessary care while avoiding unnecessary or redundant treatments. Utilization review helps control healthcare costs and maintains quality standards by reviewing cases before, during, and after care is provided. The process typically involves nurses, physicians, and other healthcare professionals who assess clinical information to make recommendations or decisions about coverage.

What are popular job titles related to Medical Utilization Review jobs in Oregon?

For Medical Utilization Review jobs in Oregon, the most frequently searched job titles are:

What job categories do people searching Medical Utilization Review jobs in Oregon look for?

The top searched job categories for Medical Utilization Review jobs in Oregon are:

Medical Utilization Review jobs near you
Infographic showing various Medical Utilization Review job openings in Oregon as of August 2026, with employment types broken down into 62% Full Time, 25% Part Time, and 13% Contract. Highlights an 62% In-person, and 38% Remote job distribution, with an average salary of $92,985 per year, or $44.7 per hour.

Utilization Review Specialist

Umpqua Health

Winston, OR • On-site

$41K - $47K/yr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 24 days ago

Job description

Utilization Review Specialist
HYBRID, must be able to travel to 3031 NE STEPHENS ST. ROSEBURG, OR 97470
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 Review Specialist supports Umpqua Health Alliance by coordinating the intake, review, processing, and completion of prior authorization requests within Medical Management. This role is responsible for ensuring accurate and timely handling of authorizations, maintaining compliance with regulatory and organizational requirements, supporting communication with providers and members, and assisting with workflow coordination to promote efficient utilization management operations.
ESSENTIAL JOB RESPONSIBILITIES
  • Support Utilization Review activities related to the prior authorization process.
  • Manage intake, tracking, and routing of prior authorization requests and supporting documentation.
  • Review requests for completeness and ensure appropriate routing for processing.
  • Communicate with healthcare providers to obtain additional information and resolve documentation issues.
  • Track prior authorization requests using established systems to ensure timely processing.
  • Support timely notification of prior authorization determinations.
  • Coordinate daily workflow and telephone coverage with team members.
  • Respond to internal and external inquiries regarding prior authorizations and route as appropriate.
  • Monitor and report on turnaround times to ensure compliance with requirements.
  • Maintain knowledge of applicable regulations, policies, and procedures.
  • Comply with organizational policies and applicable to federal, state, and local regulations.
CHALLENGES
  • Strong organizational skills with the ability to stay organized and productive in a remote, independent work environment
  • Proactive communication with internal and external stakeholders
  • Consistent ability to meet Oregon Health Plan (OHA) timeline and turnaround requirements
  • Ability to manage shifting priorities in a fast-paced environment
  • Ability to coordinate tasks and resources to meet operational goals and objectives
MINIMUM QUALIFICATIONS
  • High school diploma or equivalent.
  • Proficient computer skills, including Microsoft Office Suite (Word, Excel, Outlook, Teams), data entry, and internet research.
  • Experience using standard office equipment and systems, including keyboarding, web-based phone systems, and cloud-based document storage.
  • Ability to type a minimum of 45 words per minute with a high degree of accuracy.
  • Strong attention to detail.
  • No suspension, exclusion, or debarment from participation in federal healthcare programs (e.g., Medicare/Medicaid)
PREFERRED QUALIFICATIONS
  • 1+ years of experience in healthcare, managed care, medical coding, claims processing, or a related field
  • Knowledge of medical terminology, procedure codes, and diagnosis codes
  • Familiarity with Oregon Health Plan (OHP) and Coordinated Care Organizations (CCO), including applicable regulations (OAR, ORS, CFR, CMS, DMAP)
  • Strong organizational skills with the ability to manage multiple priorities in a fast-paced environment
  • Ability to meet deadlines while maintaining accuracy and attention to detail
  • Strong communication and customer service skills (written, verbal, and interpersonal)
  • Ability to work independently and collaboratively with sound judgment and confidentiality
  • Strong critical thinking and time management skills
  • Self-motivated with ability to follow policies, procedures, and workflows in a remote environment
  • Flexible and adaptable in a changing work environment
  • Willingness to learn and take on additional responsibilities as needed
  • Ability to work a standard schedule: Monday-Friday, 8:00 AM-5:00 PM PST
  • Experience working in diverse teams and with varied communication styles
  • Experience considering the impact of work on diverse communities, including communities of color
  • Bilingual or translation skills preferred

SCHEDULE
Monday through Friday - 8:00am - 5:00pm; standard business hours with flexibility to meet service timelines.
SALARY
Wage Band : $41,600- $47,000
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.

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