Utilization Review Clinician

Umpqua Health

Behavioral health utilization clinician reviewing mental health and substance use care for Oregon CCO Umpqua Health. Determining medical necessity, coordinating transitions, and supporting member access.

Posted 8/5/2026full-timeRoseburg • Oregon • 🇺🇸 United StatesJuniorMid-Level💰 $80,470 - $94,550 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in behavioral health evaluation, utilization management, and compliance with clinical guidelines, while effectively collaborating with multidisciplinary teams to ensure quality care and support for members. Proficient in managing treatment plans, conducting reviews, and advocating for access to appropriate services.

Highest-signal resume keywords

LCSW, LPC, LMFT, Or RN LicenseBehavioral Health Certification (PMH-BC Or CADC I)Behavioral Health Utilization ManagementClinical Knowledge Of Mental Health And Substance Use TreatmentExperience With Prior Authorization And Care Coordination

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Behavioral Health EvaluationUtilization ManagementClinical DocumentationDischarge PlanningQuality Improvement ProcessesMedical Necessity AssessmentCare CoordinationTreatment Plan AssessmentEvidence-Based Criteria ApplicationMultidisciplinary Collaboration

Soft Skills

Cultural AwarenessProfessionalismConfidentialityCommunicationProblem-Solving

Tools & Technologies

Microsoft OfficeElectronic Health Records

Certifications & Qualifications

LCSWLPCLMFTRNPMH-BCCADC I

Industry Keywords

Behavioral HealthSubstance Use DisorderManaged CareHealth Plan BenefitsCommunity ResourcesFederal Healthcare ProgramsOAROHPMedicare GuidelinesGrievance And Appeal Requirements

About the role

Key responsibilities & impact

Evaluate behavioral health and substance use disorder services for medical necessity, level of care, benefit eligibility, and compliance with clinical guidelines
Review behavioral health, Health-Related Social Needs, and Flexible Services requests for appropriateness and coverage
Conduct prospective, concurrent, and retrospective reviews, including inpatient behavioral health reviews, discharge planning, and transitions of care
Apply clinical judgment and evidence-based criteria to make utilization decisions and identify cases requiring Medical Director review
Request and evaluate additional clinical information from providers and members
Complete appeal reviews with the Grievance and Appeals team
Collaborate with care management teams, providers, and internal departments to support integrated behavioral and physical healthcare
Advocate for members' access to timely, effective care in the least restrictive appropriate setting
Support transitions from inpatient, residential, acute care, and Oregon State Hospital settings to community-based services
Identify barriers to care and support solutions promoting continuity and improved outcomes
Partner with providers and healthcare teams regarding treatment plans, level of care, and utilization management processes
Educate providers, members, and families about behavioral health benefits, services, and resources
Develop and maintain relationships with community providers and organizations
Maintain compliance with Umpqua Health policies, contractual requirements, OAR, OHP, Medicare guidelines, and grievance and appeal requirements
Maintain accurate, timely, comprehensive clinical documentation
Conduct quality reviews and audits for process improvement
Meet departmental productivity, accuracy, quality, and turnaround-time expectations
Collaborate with Third-Party Recovery and Customer Care teams regarding coverage, eligibility, and coordination of benefits
Participate in clinical rounds, case reviews, and interdisciplinary discussions
Provide training and support to new employees and cross-functional teams
Perform other assigned duties

Requirements

What you’ll need

Current Oregon license to practice independently as an LCSW, LPC, LMFT, or RN with Behavioral Health certification such as PMH-BC, or CADC I certification at minimum
Master's degree in Social Work, Counseling, Psychology, Nursing, or a related behavioral health field
Two to four years of behavioral health, substance use disorder, addiction treatment, or care management experience
Clinical knowledge of mental health and substance use treatment
Ability to assess treatment plans and medical necessity
Eligible to participate in federal healthcare programs; no Medicare/Medicaid suspension, exclusion, or debarment
Proficiency with Microsoft Office and standard computer systems
Valid driver's license and proof of current automobile insurance
Must not be suspended, excluded, or debarred from federal healthcare programs
Experience in behavioral health utilization management/utilization review, case management, or managed care preferred
Experience with prior authorization, concurrent review, discharge planning, and care coordination preferred
Knowledge of health plan benefits, community resources, electronic health records, and quality improvement processes preferred
Ability to manage multiple priorities independently in a fast-paced environment
Ability to collaborate with providers, multidisciplinary teams, and diverse communities while maintaining cultural awareness, professionalism, confidentiality, and regulatory compliance
Current clinical knowledge and applicable certifications
Bilingual translation skills are a plus
Must be available Monday through Friday, 8:00 AM–5:00 PM PST
Must live in Oregon and be willing to travel onsite if needed
Must be authorized to work for any U.S. employer without restriction and without employer sponsorship

Benefits

Comp & perks

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
Professional development opportunities
Mentorship and clear career pathways
Flexibility and well-being support for work/life balance