Reviewer Jobs in Oregon (NOW HIRING)

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If this opportunity aligns with your strengths, background, and commitment to fostering inclusivity, we encourage you to apply! At the Oregon Health Authority (OHA), we value diversity and encourage applicants from all backgrounds and experiences to help us build a stronger, more equitable future for all.

Opportunity Awaits, Apply Today! - Qualified Clinical Reviewer & Program Coordinator (Medical Review Coordinator)

We have 15 positions to be filled incrementally over the next 6 months. 8 positions are slotted for our first round of onboarding.

The Provider Clinical Support Services unit within the Oregon Health Authority's Medicaid Division supports Oregon Health Plan (OHP) Fee-for-Service (FFS) utilization management by ensuring members receive clinically appropriate, medically necessary, and policy-compliant health care services. The unit provides clinical expertise for prior authorization reviews, claims determinations, Medical Management Committee reviews, provider consultation, administrative hearings, and Oregon Administrative Rule (OAR) development. The team works closely with health care providers, Coordinated Care Organizations (CCOs), and internal agency partners to promote equitable access to medically necessary services while supporting high-quality clinical decision-making across the Medicaid program.

The Qualified Clinical Reviewer & Program Coordinator serves as a clinical authority responsible for reviewing complex medical documentation, interpreting clinical policy, and making evidence-based determinations that directly impact Oregon Health Plan members' access to care. In this position, you will conduct prior authorization and claims reviews, provide consultation to providers and agency staff, support the Medical Management Committee, serve as an expert witness during administrative hearings, and contribute to policy development, quality improvement, and program oversight. You will also monitor clinical trends, evaluate program effectiveness, collaborate with healthcare partners to improve continuity of care, and help ensure Medicaid services are delivered consistently, equitably, and in compliance with state and federal requirements.

It will be your responsibility and privilege to factor in the perspectives of diverse populations most harmed by social injustice and inequities including communities of color, immigrant groups, the disability and neurodivergent communities, veterans, older adults, individuals identifying as LGBTQIA+ and other communities that have been traditionally marginalized.

For a full review of the position description, pleaseclick here.

What We Are Looking For

Minimum Qualifications: These qualifications must be reflected in your application for consideration.

A current Registered Professional Nurse license issued by the Oregon State Board of Nursing at the time of appointment and maintained throughout employment AND three years of nursing experience that includes review of medical records.

Desired Attributes: The following are desired attributes that we have identified as key to success for this role at OHA. These are the attributes we are looking for in our top candidate. If you have any of these, please let us know in your application.

• Knowledge of professional registered nursing practice, medical terminology, and national, statewide, and community standards of clinical care; experience applying clinical judgment to review complex medical documentation, verify medical necessity, and make independent clinical decisions related to prior authorization, claims review, utilization management, and quality assurance.
• Knowledge of health services delivery systems, particularly the Oregon Health Plan (Medicaid), including experience working with Fee-for-Service programs, Coordinated Care Organizations (CCOs), health care providers, hospitals, or other clinical partners.
• Knowledge of federal and state Medicaid regulations, Oregon Administrative Rules, Oregon Revised Statutes, and clinical policy; experience interpreting and applying laws, rules, regulations, and medical necessity criteria to ensure equitable, compliant, and consistent coverage authorization determinations.
• Strong oral and written communication skills across a variety of forums, including emails, reports, meetings, committees, and administrative hearings; experience preparing clear clinical documentation, reports, and determination letters and communicating complex medical and regulatory information in ways that are accessible, culturally responsive, and appropriate for audiences with different levels of understanding.
• Experience building collaborative relationships and effectively navigating challenging interactions with providers, members, leadership, and multidisciplinary partners while gathering information, resolving issues, and supporting continuity of care.
• Experience conducting clinical research, evaluating conflicting information, identifying root causes of issues, and synthesizing quantitative and qualitative information to support quality assurance, program improvement, and evidence-based decision making.
• Experience supporting policy development and implementation, utilization management, program monitoring, quality improvement, or healthcare operations through data analysis, policy interpretation, and collaboration across healthcare programs and partners.
• Evidence of ongoing development of personal cultural awareness and humility, and experience considering the perspectives of communities disproportionately impacted by health inequities when making clinical, policy, or program decisions.

Application Guidance

Your candidate profile and application are your opportunity to showcase your skills and interest in this role. Submissions will be reviewed for clarity, consistency, and communication skills, and for alignment with the guidance provided in the below:

Submission Requirements:

• Resume - Attach your current resume that clearly outlines your education and work experience relevant to this position.
• Supplemental Questions - Answer all supplemental questions completely and accurately.
• Final Check! - Before submitting, confirm that all required materials are included, and your Workday Job History is current. The information in your application will be used to complete an Equal Pay Analysis to determine salary placement upon hire. Visit the Equal Pay Analysis Webpage for more information.

• External Candidates: Visit the State of Oregon job opportunities webpage or click the "Apply" tab above to submit your application, following all submission requirements.
• Internal Candidates: Current State of Oregon employees must apply through their employee Workday login, following all submission requirements.

After You Apply:

• Complete any pending tasks in Workday under "My Applications" prior to the application deadline.
• Check your email (including junk folder) and Workday inbox regularly for updates on your application.

Reminders:

• Eligible veterans and Oregon National Guard servicemembers (current and former) who meet the qualifications of the position will be awarded candidate preference. To protect your information and ensure correct processing, please follow the instructions for submitting your Veterans' Preference documentation.
• Please download and save a copy of this job announcement and linked position description, as it is not available after the application deadline.

About the Team & Benefits of Joining

We offer a workplace that balances productivity with enjoyment;promote an atmosphere of mutual respect, dedication, and enthusiasm. You will collaborate with a team of bright individuals to work with and learn from.

If you're driven by the passion to do something meaningful that changes lives, the Oregon Health Authorityis the place for you. We also offer a competitive benefits package including:

• Excellent, low-cost medical, vision, and dental coverage for you and your family.
• Optional benefits like life insurance, disability coverage, deferred compensation, and FSA options for health and childcare.
• Generous paid time off: 11 holidays, 3 personal days, monthly sick leave, and vacation accrual starting at 8 hours/month.
• Potential eligibility for the Public Service Loan Forgiveness Program.
• Retirement security through Public Employees Retirement System (PERS)/Oregon Public Service Retirement Plan (OPSRP).
• Training and development opportunities to grow your career with the State of Oregon.

Additional Details

• This announcement is for fifteen (15), full-time, permanent, SEIU represented, Qualified Clinical Reviewer & Program Coordinator (Medical Review Coordinator) positions based in Salem, Oregon.
• These are hybrid (15% in-office, 85% remote) positions. "Review Section 4: Working Conditions" in the position description (linked above) for more information.
• Employment is contingent upon a criminal records check and a driving records check that meets OHA criteria at the time of hire and throughout employment.
• The salary listed is the non-PERS qualifying range. If the successful candidate qualifies for PERS, the salary range will increase by 6.95%. For more information, see the Classification and Compensation page.
• The State of Oregon does not request or require your age, date of birth, attendance or graduation dates from an education institution during the application process.
• This position does not provide visa sponsorship. Within three days of hire, you will be required to complete I-9 documentation and confirm authorization to work in the United States. OHA will use E-Verify to verify work authorization. If your employment eligibility depends on sponsorship now or in the future, you will not meet the requirements for this position.
• We evaluate candidates based on their own skills and experience. Unless explicitly approved, outside resources - including Artificial Intelligence (AI) tools - are not permitted during assessments or interviews. Use of unauthorized resources will disqualify a candidate from further consideration.

Contact Information
Recruiter: Stephanie Mitchell
Email: stephanie.d.mitchell@oha.oregon.gov
Phone (text friendly): (503) 979-7679

Accommodation Requests (ADA): OHA provides reasonable accommodations under the ADA, which may include alternative formats of materials or language support. If you need an accommodation to apply for this position or participate in the selection process, please contact the recruiter listed above.

Helpful Links & Resources

How to Set Job Alerts | Workday Applicant FAQ | Oregon Health Authority | Facebook | Instagram | LinkedIn | Veterans Resources | What You Need to Know to Get the Job

The Oregon Health Authority is an affirmative action and equal opportunity employer, committed to fair employment practices and pay equity for all employees. We do not discriminate based on protected class - including race, sex, veteran status, disability, age, color, religion, national origin, marital status, or sexual orientation - and does not screen applicants based on current or past compensation. Salary is determined through a fair review of your education, experience, and training as it relates to the position.

OHA is an anti-racist organization working to eliminate health inequities and dismantle structural barriers that impact underserved communities. Join us in advancing our Strategic Plan and building a more equitable Oregon.