Job Description

Position Purpose:
The Utilization Management Nurse evaluates clinical service requests to ensure medically necessary, cost-effective, and evidence-based care for members. This role conducts prior authorizations, facilitates care coordination, and supports safe transitions across care settings, ensuring compliance with Oregon Health Plan (OHP), Medicare, and applicable regulations. The UM Nurse collaborates with interdisciplinary teams and community providers to promote integrated, high-quality care.

Essential Responsibilities:

• Perform clinical assessments and prior authorizations to determine medical necessity
• Escalate complex cases to Medical Directors and request additional documentation as needed
• Collaborate with care coordinators, discharge planners, and interdisciplinary teams for care transitions
• Liaise with internal departments to resolve eligibility, benefits, or service issues
• Participate in discharge planning for members transitioning from acute, long-term, or residential care
• Conduct audits and support quality improvement initiatives
• Provide training and mentorship on UM protocols and workflows
• Maintain relationships with community providers and service organizations
• Ensure compliance with organizational policies, clinical standards, and federal/state regulations
• Perform other nursing-related duties as assigned

Minimum Qualifications:

• Active, unrestricted RN license (BSN or MSN) in Oregon or a compact state
• Graduation from an accredited nursing program
• Minimum 5 years of direct patient care experience
• Proficiency with Microsoft Office, EHR systems, and UM software
• Strong clinical knowledge, communication, and organizational skills
• No suspension, exclusion, or debarment from federal healthcare programs

Preferred Qualifications:

• 2+ years of utilization review or case management experience in managed care
• Oregon residency and license
• Bilingual or translation skills a plus
• Experience with quality improvement audits and diverse team collaboration
• Ability to work independently in fast-paced environments

Job Tags

Similar Jobs