Qualified Clinical Reviewer, Program Coordinator

Oregon Department of Human Services

Oregon Health Authority clinical reviewer evaluating Medicaid prior authorizations, claims, and medical necessity. Coordinating policy, hearings, quality improvement, and equitable access to Oregon Health Plan services.

Posted 8/4/2026full-timeSalem • Oregon • 🇺🇸 United StatesMid-LevelSenior💰 $7,347 - $11,152 per monthWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in prior authorization, claims review, and clinical policy interpretation, with a strong focus on Medicaid services and compliance with state and federal regulations. Proven ability to build collaborative relationships and effectively communicate complex medical information to diverse stakeholders.

Highest-signal resume keywords

Registered Professional Nurse LicensePrior Authorization ReviewMedical Documentation ReviewMedicaid Regulations KnowledgeClinical Decision-Making

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical TerminologyClinical Care StandardsUtilization ManagementQuality AssuranceClinical ResearchPolicy DevelopmentProgram MonitoringEvidence-Based DeterminationsClaims ReviewMedical Necessity Verification

Soft Skills

Strong Communication SkillsCultural AwarenessRelationship BuildingNavigating Challenging InteractionsCollaboration

Certifications & Qualifications

Registered Professional Nurse License

Industry Keywords

Oregon Health PlanCoordinated Care OrganizationsHealth Services Delivery SystemsOregon Administrative RulesOregon Revised StatutesSocial InjusticeHealth Inequities

About the role

Key responsibilities & impact

Conduct prior authorization and claims reviews
Review complex medical documentation and interpret clinical policy
Make evidence-based determinations affecting Oregon Health Plan members' access to care
Provide consultation to health care providers and agency staff
Support the Medical Management Committee
Serve as an expert witness during administrative hearings
Contribute to policy development, quality improvement, and program oversight
Monitor clinical trends and evaluate program effectiveness
Collaborate with health care partners to improve continuity of care
Help ensure Medicaid services are delivered consistently, equitably, and in compliance with state and federal requirements
Consider perspectives of communities disproportionately affected by social injustice and health inequities

Requirements

What you’ll need

Current Registered Professional Nurse license issued by the Oregon State Board of Nursing at the time of appointment and maintained throughout employment
Three years of nursing experience that includes review of medical records
Knowledge of professional registered nursing practice, medical terminology, and clinical care standards
Experience reviewing complex medical documentation, verifying medical necessity, and making clinical decisions related to prior authorization, claims review, utilization management, and quality assurance
Knowledge of health services delivery systems, particularly Oregon Health Plan Medicaid and Fee-for-Service programs
Knowledge of Coordinated Care Organizations, health care providers, hospitals, or other clinical partners
Knowledge of federal and state Medicaid regulations, Oregon Administrative Rules, Oregon Revised Statutes, clinical policy, and medical necessity criteria
Strong oral and written communication skills
Experience preparing clinical documentation, reports, determination letters, and communicating medical and regulatory information accessibly and culturally responsively
Experience building collaborative relationships and navigating challenging interactions with providers, members, leadership, and multidisciplinary partners
Experience conducting clinical research, evaluating conflicting information, identifying root causes, and synthesizing quantitative and qualitative information
Experience supporting policy development, utilization management, program monitoring, quality improvement, or healthcare operations
Evidence of ongoing cultural awareness and humility
Must pass criminal records and driving records checks meeting OHA criteria
Must be authorized to work in the United States; position does not provide visa sponsorship

Benefits

Comp & perks

Excellent, low-cost medical, vision, and dental coverage for you and your family
Optional life insurance, disability coverage, deferred compensation, and FSA options for health and childcare
11 holidays
3 personal days
Monthly sick leave
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
Reasonable accommodations under the ADA, which may include alternative formats of materials or language support