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Utilization Management Auditor Jobs in Oregon (NOW HIRING)

Adventist Health

Chart Auditor (Portland)

Portland, OR · On-site

Adventist Health Portland is looking for Chart Auditor for Full-time, Day Shift. We are looking for ... Collaborates with Case Management, Utilization Management, Coding, Medical Officer, and Physician ...

Adventist Health

Chart Auditor (Portland)

Portland, OR · On-site

$52.55 - $78.77/hr

Adventist Health Portland is looking for Chart Auditor for Full-time, Day Shift. We are looking for ... Collaborates with Case Management, Utilization Management, Coding, Medical Officer, and Physician ...

Cotiviti

Sales VP, Pharmacy Claim Editing Solutions

... utilization management, benefit configuration, and post-pay or pre-pay accuracy programs highly ... claims auditing . * Represent Cotiviti at pharmacy related conferences, industry forums, and ...

Curana Health, Inc.

... auditing, resolving, and reporting on cases. * Respond to member and provider appeals and ... Collaborate with Utilization Management, Claims, Provider Network, Legal, Compliance, and other ...

Mosaic Medical

Staff Scheduling Analyst

Bend, OR

The Staff Scheduling Analyst is responsible for auditing the scheduling system to ensure standards ... Manage open shifts and shift swaps approvals in collaboration with local leadership to ensure ...

Mosaik Medical

Staff Scheduling Analyst

Bend, OR · On-site

The Staff Scheduling Analyst is responsible for auditing the scheduling system to ensure standards ... Manage open shifts and shift swaps approvals in collaboration with local leadership to ensure ...

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Utilization Management Auditor information

What is the difference between Utilization Management Auditor vs Utilization Review Nurse?

AspectUtilization Management AuditorUtilization Review Nurse
CredentialsTypically requires a nursing license, certifications like CCM or CUCLicensed Registered Nurse (RN), often with additional certifications
Work EnvironmentOffice-based, insurance companies, healthcare organizationsHospital, clinics, insurance companies, often in clinical settings
Primary FocusAuditing and reviewing utilization data for compliance and cost managementAssessing patient care needs and determining appropriate services

While both roles involve healthcare utilization, the Utilization Management Auditor primarily reviews data for compliance and cost efficiency, whereas the Utilization Review Nurse focuses on patient care assessments. Both require nursing credentials and work within healthcare or insurance settings, but their core responsibilities differ.

What are some common challenges faced by utilization management auditors and how can they be addressed?

Utilization Management Auditors often encounter challenges such as keeping up with constantly changing healthcare regulations and payer requirements, interpreting complex medical documentation, and ensuring compliance with both internal and external policies. To address these challenges, auditors should engage in ongoing professional development, collaborate closely with clinical and administrative teams for accurate information, and make use of robust audit tools and resources. Effective communication and a proactive approach to regulatory changes can help streamline the audit process and maintain high standards of accuracy.

What is a utilization management auditor?

A Utilization Management Auditor is a healthcare professional responsible for reviewing medical records, claims, and utilization data to ensure that healthcare services provided to patients are necessary, appropriate, and comply with established guidelines and policies. They help identify overuse, underuse, or misuse of medical resources and ensure regulatory compliance. Utilization Management Auditors work closely with healthcare providers, insurance companies, and regulatory agencies to improve the quality and cost-effectiveness of patient care.

What are the key skills and qualifications needed to thrive as a utilization management auditor?

To thrive as a Utilization Management Auditor, you need a strong background in healthcare administration, case management, and medical coding, often supported by a clinical degree or certification such as RN, LPN, or RHIA. Familiarity with utilization management software, electronic health records (EHRs), and regulatory standards like CMS guidelines is essential. Analytical thinking, attention to detail, and effective communication are crucial soft skills for identifying compliance issues and collaborating with healthcare teams. These skills ensure accurate audits, regulatory compliance, and optimal resource utilization within healthcare organizations.
What are popular job titles related to Utilization Management Auditor jobs in Oregon? For Utilization Management Auditor jobs in Oregon, the most frequently searched job titles are:
What job categories do people searching Utilization Management Auditor jobs in Oregon look for? The top searched job categories for Utilization Management Auditor jobs in Oregon are:
What cities in Oregon are hiring for Utilization Management Auditor jobs? Cities in Oregon with the most Utilization Management Auditor job openings:
Utilization Management Auditor jobs near you

Chart Auditor (Portland)

Adventist Health

Portland, OR • On-site

Other

Re-posted 12 days ago

Adventist Health rating

7.7

Company rating: 7.7 out of 10

Based on 243 frontline employees who took The Breakroom Quiz

160th of 887 rated healthcare providers

Job description


Adventist Health Portland is looking for Chart Auditor for Full-time, Day Shift. We are looking for great individual who can work onsite to our location in Portland, OR
Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.
Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.
Job Summary:
Supports the Revenue Management Department by auditing medical records and clinical documentation to ensure proper patient status placement, accurate coding, and defensible payer billing. Focuses on clinical denials, observation services, documentation gaps, and payer requirements for authorization and coverage. Collaborates with Case Management, Utilization Management, Coding, Medical Officer, and Physician Advisors to reduce clinical denials, improve documentation quality, and ensure compliance with regulatory and payer standards. Provides analytic reports and feedback to identify systemic trends and educational opportunities.
Job Requirements:
Education and Work Experience:
  • Associate's degree in Nursing or related clinical field: Required
  • Bachelor's Degree in Nursing (BSN) or Healthcare Administration: Preferred
  • Prior experience in utilization review, case management, coding, or clinical auditing: Preferred
Licenses/Certifications:
  • Current licensed RN in the state of practice (RN), medical provider (MD), or International Medical Graduate with valid credential: Required
  • Registered Nurse (RN) or Medical license MD (MD) or Foreign Medical Doctor (FMD): Required
Essential Functions:
  • Conducts concurrent audits of active cases to identify documentation and order issues in real time, preventing downstream denials. Applies InterQual or Milliman/MCG criteria to validate patient status decisions and payer medical necessity compliance.
  • Reviews medical records to validate patient placement (inpatient vs. observation) against payer criteria and physician orders. Audits clinical denials to determine root cause, trends, and opportunities for appeal, and recommends actionable prevention strategies. Performs charge audits and account reconciliations to ensure documentation is appropriate, compliant with regulations, and free of denial risk. Provides recommendations for charge corrections and technical assistance in staff training.
  • Identifies barriers to clean claims and timely payment; tracks and trends denials, escalating systemic issues to the Director/Manager. Tracks and trends payer clinical denials, observation hours, and placement errors; prepares reports for Revenue Management leadership. Provides feedback to Coding and CDI teams regarding documentation needed for coding accuracy and DRG assignment.
  • Partners with Case Management, Utilization Management, Medical Officer, and Physician Advisors to ensure accurate clinical documentation and timely status changes. Collaborates in payer escalations and appeal preparation by supplying clinical and documentation findings. Educates providers and staff on documentation, status order accuracy, and denial prevention strategies.
  • Monitors CMS, state, and commercial payer regulatory changes impacting clinical documentation, placement, and observation requirements; integrates updates into audit practices. Demonstrates reliability, responsiveness, and effective follow-up on matters requiring attention.
  • Performs other job-related duties as assigned.

Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.
About Us
Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.

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