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Remote Utilization Management Jobs in Portland, OR

Moda Health

Manager, Clinical Pharmacy

Portland, OR · Remote

... however, remote status will also be considered. Pay Range $150,000.00- $200,000.00 annually ... utilization management, prior authorization, and other clinical pharmacy programs. * Provide ...

IME Resources

Pharmacy Technician (32410)

Portland, OR · Remote

$18.50 - $22.50/hr

This position is 100% remote and full time. Responsibilities may include: * Performs quality ... AllMed provides clinical decision making and utilization management solutions to leading payer and ...

Directive

Paid Social Manager (Remote US)

Portland, OR · Remote

... a CRM * Responsible for personal productivity and utilization * Work directly with Associate ... remote-first company, you'll have the ability to work from anywhere in the US, with the option to ...

ITW

National Sales Manager

OR · Remote

The role is a remote position; location base will be reviewed as this position covers all regions ... Develop communication and territory management skills throughout the field sales team * Identify ...

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All JobsUtilization Management JobsRemote Utilization Management JobsRemote Utilization Management Jobs in Portland, OR

Remote Utilization Management information

See Portland, OR salary details

$22

$44

$73

How much do remote utilization management jobs pay per hour?

As of Jul 14, 2026, the average hourly pay for remote utilization management in Portland, OR is $44.84, according to ZipRecruiter salary data. Most workers in this role earn between $35.43 and $51.49 per hour, depending on experience, location, and employer.

How does a Remote Utilization Management professional typically collaborate with healthcare providers and insurance teams?

Remote Utilization Management professionals frequently interact with both healthcare providers and insurance teams through secure digital platforms, phone calls, and virtual meetings. They review patient records, assess the necessity of medical services, and communicate their recommendations or authorization decisions. Effective collaboration requires clear documentation, timely responses, and strong communication skills to ensure that care is both medically appropriate and cost-effective. While the work is often independent, regular coordination with interdisciplinary teams is essential for maintaining high-quality patient outcomes and adhering to regulatory standards.

What are the key skills and qualifications needed to thrive as a Remote Utilization Management Nurse, and why are they important?

Success as a Remote Utilization Management Nurse requires a registered nursing license, clinical experience, and strong knowledge of medical necessity criteria and insurance guidelines. Familiarity with utilization review software, electronic health records (EHRs), and case management systems is typically necessary. Exceptional communication, critical thinking, and organizational skills help professionals excel in evaluating cases and coordinating with providers remotely. These skills are crucial for ensuring appropriate care, cost-effective resource use, and regulatory compliance in a remote healthcare setting.

What is remote utilization management?

Remote utilization management is a process in which healthcare professionals, such as nurses or case managers, review and assess the necessity, efficiency, and appropriateness of medical services—often from a remote location. These professionals typically work for insurance companies, hospitals, or healthcare organizations to ensure that patients receive the right care while controlling costs. By working remotely, they use electronic health records, phone calls, and other digital tools to collaborate with providers and patients. This role helps improve healthcare quality and cost-effectiveness while allowing employees flexible work arrangements.

What is the difference between Remote Utilization Management vs Remote Case Management?

AspectRemote Utilization ManagementRemote Case Management
CredentialsRN, LPN, or licensed healthcare professionalsRN, LPN, or social workers
Work EnvironmentHealthcare facilities, insurance companies, telehealthHealthcare providers, insurance, community agencies
Industry UsageInsurance, healthcare, telehealthHealthcare, social services, insurance
Primary FocusReviewing medical necessity, authorizationsCoordinating patient care, support services

Remote Utilization Management primarily involves reviewing medical necessity and authorizations, while Remote Case Management focuses on coordinating patient care and support services. Both roles require healthcare credentials and are used within healthcare and insurance industries, but they serve different functions in patient care and resource allocation.

What are the most commonly searched types of Utilization Management jobs in Portland, OR? The most popular types of Utilization Management jobs in Portland, OR are:
What are popular job titles related to Remote Utilization Management jobs in Portland, OR? For Remote Utilization Management jobs in Portland, OR, the most frequently searched job titles are:
What job categories do people searching Remote Utilization Management jobs in Portland, OR look for? The top searched job categories for Remote Utilization Management jobs in Portland, OR are:
What cities near Portland, OR are hiring for Remote Utilization Management jobs? Cities near Portland, OR with the most Remote Utilization Management job openings:
Remote Utilization Management jobs near you
Infographic showing various Remote Utilization Management job openings in Portland, OR as of July 2026, with employment types broken down into 1% As Needed, 82% Full Time, 14% Part Time, 1% Temporary, and 2% Contract. Highlights an 87% Physical, 3% Hybrid, and 10% Remote job distribution, with an average salary of $93,268 per year, or $44.8 per hour.
Registered Nurse / RN - Utilization Management I

Registered Nurse / RN - Utilization Management I

CareOregon

Portland, OR • On-site, Remote

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 21 days ago

CareOregon rating

7.6

Company rating: 7.6 out of 10

Based on 7 frontline employees who took The Breakroom Quiz

191st of 281 rated insurance

Job description

Registered Nurse / RN - Utilization Management I
The Registered Nurse - Utilization Management I is responsible for supporting specific utilization management (UM) program functions within the Clinical Operations department. UM program functions include Benefit Management, Benefit Review, Appeals and Grievances and Health Related Services (HRS). Together they support the healthcare needs of members, determine the best medically appropriate services, and apply clinical-based criteria for decision-making while managing medical expenses.
Estimated Hiring Range:
$102,330.00 - $125,070.00
Bonus Target:
Bonus - SIP Target, 5% Annual
Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.
Essential Responsibilities
General Duties
  • Communicate with members and/or providers in a professional manner and in accordance with State and Federal requirements as needed to complete requests.
  • Maintain confidentiality of all discussions, records, and other data in connection with quality management activities according to professional standards.
  • Refer members to care coordination per policies and procedures.
  • Maintain accurate and complete documentation.
  • Collaborate with Medical Directors to determine medical necessity and appropriateness of care for benefits requested and/or rendered.
  • Work with clinical support staff to ensure service requests, authorizations and/or grievances are managed in accordance with state and federal guidelines.
  • Identify and refer potential quality of care issues for peer review.
  • Ensure that authorization decisions are based on organizational policy and state and federal coverage rules.
  • Gather and submit documents for third party case review; this includes all documentation and follow-up activities.
  • Issue denial notices based on established unit protocols and state and/or federal requirements.
  • Assist with periodic audits, general quality management and improvement activities, and other regulatory activities as needed.
  • Foster collaboration with teams across the Clinical Operations department to ensure work and goals are met.
  • Meet or exceed department production, timelines, and quality standards established for level I.
  • May participate in departmental workgroups or projects as assigned.
  • Support testing for system updates and implementations as assigned.
  • May help train new staff and teammates as assigned.
  • Cross train in additional functional focus areas as assigned.

Duties Specific to Functional Focus Area
  • Benefit Management
    • Review provider pre-service requests and determine benefit coverage according to Medicare, Medicaid and/or organizational guidelines.
  • Benefit Review
    • Determine appropriate level of care and length of stay for inpatient members to include hospitals, skilled nursing facilities, long term acute care hospitals, inpatient rehabilitation hospitals, and respite care programs.
    • Review inpatient admission for re-insurance clinical reporting.
  • Appeals and Grievance
    • Assemble evidence and build clinical cases for administrative hearings or Independent Review Entity (IRE) reviews.
    • Function as a CareOregon representative in administrative hearings.
    • Assist with the analysis and summary of data for written reports and public presentations as needed.
    • Communicate with members, providers, health plan administrators to manage grievances and appeals and provide case status updates as needed.
    • Investigate and use clinical judgement to identify quality of care or safety issues and present findings to an oversight committee.
  • Health Related Services
    • Review provider and member submitted HRSN and Flexible Services requests and determine benefit eligibility according to Medicaid and/or organizational guidelines.

Experience and/or Education
Required
  • Current unrestricted Oregon RN license
  • Minimum 2 years RN experience [OR 1 year RN experience AND 3 years' experience in healthcare setting role(s) such as billing, coding, medical assistant, etc.]

Preferred
  • More than 1 year RN experience
  • Healthcare utilization management experience in Prior Authorization UM
  • Experience with Medicaid and/or Medicare utilization management

Knowledge, Skills and Abilities Required
Knowledge
  • Knowledge of Medicaid health plan and Medicare benefits
  • Knowledge of applicable DMAP rules and regulations
  • Knowledge of ICD-10, CPT, and HCPCS codes
  • Familiarity with the principles of utilization management
  • Familiarity with healthcare documentation systems

Skills and Abilities
  • General computer skills including use of Microsoft Office applications and internet search functions
  • Ability to use review criteria in accordance with departmental policies
  • Ability to adhere to HIPAA regulations e.g., maintaining confidentiality of protected health information
  • Ability to interpret and apply complex policies and procedures
  • Ability to review work for accuracy
  • Ability to independently prioritize work
  • Ability to use critical thinking and problem-solving skills
  • Strong spoken and written communication skills
  • Strong interpersonal and customer service skills
  • Ability to work effectively with diverse individuals and groups
  • Ability to learn, focus, understand, and evaluate information and determine appropriate actions
  • Ability to accept direction and feedback, as well as tolerate and manage stress
  • Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
  • Ability to hear and speak clearly for at least 3-6 hours/day

Working Conditions
Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure
Member/Patient Facing: ☒ No ☐ Telephonic ☐ In Person
Hazards: May include, but not limited to, physical and ergonomic hazards.
Equipment: General office equipment
Travel: May include occasional required or optional travel outside of the workplace; the employee's personal vehicle, local transit or other means of transportation may be used.
Work Location: Work from home
We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.
We are an equal opportunity employer
CareOregon is an equal opportunity employer. The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.

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