Utilization Review Specialist Team Lead
Umpqua HealthHYBRID, must be able to travel to 3031 NE STEPHENS ST. ROSEBURG, OR 97470
EMPLOYMENT TYPE: Full-Time, Exempt
About Umpqua Health
POSITION PURPOSE
The Utilization Review Specialist Team Lead provides support to Umpqua Health Alliance (UHA) in the intake, processing, and finalization of prior authorizations received by Medical Management in compliance with regulatory requirements. This role provides day-to-day operational support to the Utilization Management (UM) department by assisting with workflow coordination, staff guidance, and process oversight for non-licensed team members. The Team Lead serves as a key resource to ensure work queues are managed efficiently, productivity and turnaround time expectations are met, and departmental processes are consistently followed. This position also supports managers with staff training, onboarding, and mentoring, while helping identify workflow issues and opportunities for process improvement. Additionally, the Team Lead acts as a primary operational point of contact for team members, assisting with workload coordination, addressing questions, and escalating issues as needed. This role supports efficient UM operations while ensuring compliance with organizational policies and regulatory requirements.
ESSENTIAL JOB RESPONSIBILITIES
Provide daily operational support for Utilization Review and Care Coordination related to prior authorizations.
Manage intake, tracking, processing, and routing of prior authorizations, appeals, grievances, and related documentation.
Monitor work queues to ensure timely processing and compliance with turnaround requirements.
Prioritize urgent or time-sensitive requests and route appropriately to clinical staff.
Coordinate workflow distribution and telephone coverage among team members.
Serve as a resource regarding workflows, systems, and standard procedures.
Troubleshoot routine operational issues and escalate complex concerns as needed.
Respond to and route internal and external prior authorization inquiries appropriately.
Assist with onboarding, training, and maintaining workflow and training materials.
Conduct quality reviews to ensure accuracy, completeness, and timely processing.
Identify workflow trends and process improvement opportunities and report findings to leadership.
Support audits, reporting, quality improvement initiatives, and system or workflow updates.
Participate in departmental meetings, trainings, and compliance activities.
Maintain knowledge of applicable regulations, policies, and compliance requirements.
Working with a variety of personalities, maintaining a consistent and fair communication style.
Satisfying the needs of a fast-paced and challenging company.
Balancing regulatory compliance, member-centered care, and operational efficiency in a complex and evolving CCO environment.
High school diploma or equivalent
Proficient computer skills, including MS Office (Word, Excel, Outlook), data entry, internet research, and basic office systems (e.g., web-based phone queues, cloud document storage)
Ability to type at least 45 wpm with a high degree of accuracy
High attention to detail with strong accuracy in data entry and documentation
Ability to manage multiple priorities, organize work, and meet deadlines in a fast-paced environment
Strong interpersonal, written, and verbal communication skills with the ability to interact professionally with internal and external customers
Ability to work effectively both independently and as part of a team while maintaining confidentiality
Willingness to learn new skills and take on new responsibilities
Ability to work remotely Monday–Friday, 8:00 AM–5:00 PM PST
No suspension, exclusion, or debarment from federal healthcare programs (e.g., Medicare/Medicaid)
Valid driver’s license and current automobile insurance required.
1+ years of experience in healthcare, managed care (utilization), medical coding, claims, or related field
Knowledge of medical terminology, procedure codes, and diagnosis codes
Familiarity with Oregon Health Plan (OHP) and Coordinated Care Organizations (CCO), including OAR, ORS, CFR, CMS, DMAP, and the Prioritized List of Health Services
Experience working in diverse teams and with varied communication styles
Experience considering health equity impacts in analytical or operational work
Bilingual or translation capabilities preferred
Strong critical thinking and time management skills to prioritize workload and meet turnaround times consistently
Monday through Friday - 8:00am - 5:00pm; standard business hours with flexibility to meet service timelines.
SALARY
Wage Band: $48,000- $50,000
BENEFITS
- Salary is dependent on skills, experience, and education
- Generous benefits package including vacation PTO, sick leave, federal holidays, and birthday leave
- Medical, dental, and vision insurance
- 401(k) with company match (fully vested immediately)
- Company-sponsored life insurance and additional benefits
- Fitness reimbursement program
- Tuition reimbursement and more
Why Umpqua Health?
Inclusive Culture
We foster a respectful, inclusive environment where employees feel valued, supported, and empowered.
Growth & Development
We support ongoing learning through mentorship, clear career pathways, and professional development opportunities.
Work/Life Balance
We promote flexibility and well-being so employees can thrive both professionally and personally.
Equal Opportunity