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Prior Authorization Utilization Review Jobs in Oregon

Healthcare Support Staffing

Pharmacist

Portland, OR

$61.75 - $74.25/hr

... prior authorizations, medication therapy management and drug utilization review Additional Information Are you an experienced Pharmacist looking for a new opportunity with a prestigious healthcare ...

Moda Health

Govt Prior Auth Coord I

Portland, OR · On-site +1

$21.30 - $23.96/hr

Review and research referral and authorization requests received in Healthcare Services. Process or route per appropriate guideline. * Provides education to members and providers regarding prior ...

Moda Health

CPhT RX Prior Authorization Coord I

Portland, OR · On-site

$21.30 - $23.96/hr

Position Summary Utilizes the electronic prior authorization (PA) platform to process pharmacy PAs ... Utilizes critical decision-making skills to interpret formulary coverage and reviews PA requests ...

Kairos

Insurance Coordinator

Grants Pass, OR · On-site

Review co-pays, deductibles, coinsurance, visit limits, and authorization requirements * Accurately ... system Authorization & Utilization Management * Obtain and manage prior authorizations for ...

Soliant Health

Pharmacist in Beaverton, OR

Beaverton, OR · On-site

$61.50 - $74/hr

... prior authorizations, audits, appeals, and ALJ court hearings * Strong knowledge of clinical policy development, drug utilization review, and medication therapy management * Excellent communication ...

Kairos

Insurance Coordinator

Grants Pass, OR · On-site

$24.79 - $30.13/hr

Review co-pays, deductibles, coinsurance, visit limits, and authorization requirements * Accurately ... system Authorization & Utilization Management * Obtain and manage prior authorizations for ...

Kairos

Insurance Coordinator

Grants Pass, OR · On-site

Review co-pays, deductibles, coinsurance, visit limits, and authorization requirements * Accurately ... system Authorization & Utilization Management * Obtain and manage prior authorizations for ...

Tricehealthcare

Pharmacy - Pharmacist Inpatient

Portland, OR · On-site

$61.75 - $74.25/hr

... utilization management functions and initiatives including medical drug policy generation, review, and application including prior-authorization, general DUR, and population and group level ...

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Prior Authorization Utilization Review information

What is a Prior Authorization Utilization Review specialist?

A Prior Authorization Utilization Review specialist is a healthcare professional responsible for evaluating medical service requests to ensure they meet specific criteria for approval before services are provided. Their main role is to review clinical information, verify medical necessity, and ensure compliance with insurance policies and guidelines. They act as a liaison between healthcare providers, insurance companies, and patients to facilitate timely and accurate authorization decisions. This process helps to manage healthcare costs and ensure patients receive appropriate care.

What are the key skills and qualifications needed to thrive as a Prior Authorization Utilization Review specialist?

To thrive as a Prior Authorization Utilization Review Specialist, you need a strong understanding of medical terminology, insurance guidelines, and clinical criteria, often supported by a degree in healthcare or nursing and relevant certification (such as RN or LPN). Familiarity with prior authorization software, electronic health record (EHR) systems, and payer portals is typically required. Attention to detail, strong communication skills, and the ability to multitask help professionals excel in this role. These competencies ensure accurate and timely processing of authorizations, reducing delays in patient care and ensuring compliance with payer requirements.

What are some common challenges faced by professionals in Prior Authorization Utilization Review roles, and how can these be managed?

Professionals in Prior Authorization Utilization Review often encounter challenges such as navigating complex insurance policies, managing high volumes of requests, and ensuring timely communication between providers and payers. Staying organized, developing a thorough understanding of payer guidelines, and maintaining clear, consistent communication are key strategies for managing these challenges. Many teams also rely on workflow management tools and regular team huddles to streamline processes and ensure all cases are handled efficiently.

What is the difference between Prior Authorization Utilization Review vs Medical Reviewer?

AspectPrior Authorization Utilization ReviewMedical Reviewer
CredentialsLicensed healthcare professionals, often with certifications in utilization reviewLicensed physicians or healthcare providers with clinical expertise
Work EnvironmentInsurance companies, healthcare organizations, or third-party review firmsHospitals, clinics, insurance companies, or consulting firms
Primary FocusAssessing the necessity of procedures or treatments before approvalEvaluating clinical records to determine medical necessity and appropriateness

While both roles involve clinical assessment, Prior Authorization Utilization Review focuses on pre-authorization decisions for treatments, whereas Medical Review involves detailed clinical evaluation of patient records to determine medical necessity. Both require healthcare credentials and are integral to healthcare quality and cost management.

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

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

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

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

What cities in Oregon are hiring for Prior Authorization Utilization Review jobs?

Cities in Oregon with the most Prior Authorization Utilization Review job openings:

Prior Authorization Utilization Review jobs near you
Infographic showing various Prior Authorization Utilization Review job openings in Oregon as of August 2026, with employment types broken down into 82% Full Time, and 18% Part Time. Highlights an 100% In-person job distribution.

RCM Prior Authorization Specialist - Remote

Slocumcenter

Eugene, OR • On-site

$60 - $80/hr

Other

Posted 6 days ago

Job description

  • Submits, tracks, and manages prior authorization requests for medical and ancillary procedures, within strict timeframes.
  • Researches and resolves authorization and referral claim denials, while coordinating with physicians, providers, and insurance payers to file appeals or facilitate a P2P.
  • Reviews patient medical records and clinical documentation to ensure they meet payer coverage criteria.
  • Collaborate with the RCM Prior Authorization Supervisor and Team Lead to develop and update authorization policies and procedures.
  • Maintain knowledge of payer guidelines (Medicare, Medicaid, Commercial, etc.) and ensuring regulatory compliance.
  • Partner with the RCM Prior Authorization Supervisor and Team Lead to analyze denied claims resulting from prior authorization and referral errors by identifying the root cause and provide the corrected data to the billing team for the purpose of appealing or resubmitting a corrected claim.
  • Interacts with insurance payers, physicians, providers, and Slocum departments to clarify coverage requirements to expedite approvals.
  • Work in collaboration with the RCM Prior Authorization Supervisor and Team Lead to monitor prior authorization related utilization trends, claim denials, denial rates, and provide performance improvement suggestions to senior leadership.
  • Communicate cross-functionally with providers and other Slocum departments regarding patient questions or referral and authorization concerns.
  • Perform other duties as assigned
  • 2 – 5 years of previous experience as a Prior Authorization Specialist, with expertise in medical billing, healthcare, and the insurance referral process.
  • Strong understanding of medical terminology, ICD-10, CPT, and HCPC coding, and insurance payer policies.
  • Ability to train staff, manage high-volume workflows, and mentor team members.
  • Proficiency in medical billing software / Electronic Health Records (NextGen preferred).
  • Be able to read and understand digital and paper insurance Explanation of Benefits.
  • Strong attention to detail (Accuracy in code selection is critical for compliance and reimbursement.
  • Familiarity with CMS and insurance payer guidelines and requirements.
  • Proficient with Microsoft Office Suites (Outlook, Word, and Excel).
  • Possess the ability to prioritize workload daily, weekly and monthly.
  • Strong communication, attention to detail, and problem-solving skills
Summary
  • The RCM Prior Authorization Specialist manages insurance approvals for medical and ancillary services. Monitor the accuracy of prior authorization activity and payer requirements. Act as a liaison between providers, patients, payers. Ability to learn and retain new workflows and changes in insurance payer requirements. Ensure a high level of accuracy in clinical documentation submissions. Handle denials and appeals.
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