Medical Reviewer

• 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

Oregon Health Authority nurse reviewing Medicaid services and coordinating clinical utilization programs

Qualified Clinical Reviewer, Program Coordinator

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.

Medical Reviewer jobs in Oregon

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Qualified Clinical Reviewer, Program Coordinator