Registered Nurse - Utilization Management I

CareOregon, Inc.; Portland (OR); Remote; USD 102,000 - 125,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401(k) plan

Paid time off

Job summary

CareOregon is seeking a Registered Nurse in Utilization Management I to support UM program functions within the Clinical Operations department. The role focuses on Benefit Management, Benefit Review, Appeals and Grievances, and Health Related Services, with decisions based on clinical criteria while managing medical expenses.

Remote work with preference for Oregon/SW Washington. The position offers a competitive hiring range and 5% bonus target.

Qualifications

• Current unrestricted Oregon RN license.
• Minimum 2 years RN experience or 1 year RN + 3 years in healthcare setting roles such as billing or coding.
• Healthcare utilization management experience preferred.

Responsibilities

• Communicate with members and providers professionally per state/federal requirements.
• Maintain confidential documentation and participate in quality management activities.
• Collaborate with Medical Directors to determine medical necessity for benefits.
• Assist with audits, system testing, and training of staff.

Skills

RN license knowledge

Healthcare documentation

Utilization management

Communication skills

HIPAA/privacy

Education

RN License (Oregon)

Tools

Microsoft Office

Electronic Health Records (EHR)

Job description

Registered Nurse - Utilization Management I-The Registered Nurse - Utilization Management I is responsible for supporting specific utilization management (UM) program functions within the Clinical Operations department. UM program functions include Benefit Management, Benefit Review, Appeals and Grievances and Health Related Services (HRS). Together they support the healthcare needs of members, determine the best medically appropriate services, and apply clinical-based criteria for decision-making while managing medical expenses.NOTE: This is a remote position with preference given to candidates in Oregon and SW Washington. This position is on the Appeals and Grievances team.Estimated Hiring Range:$102,330.00 - $125,070.00Bonus Target:Bonus - SIP Target, 5% AnnualPriority will be given to candidates residing in Oregon and Southwest Washington.Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.-Essential ResponsibilitiesGeneral DutiesCommunicate with members and/or providers in a professional manner and in accordance with State and Federal requirements as needed to complete requests.Maintain confidentiality of all discussions, records, and other data in connection with quality management activities according to professional standards.Refer members to care coordination per policies and procedures.Maintain accurate and complete documentation.Collaborate with Medical Directors to determine medical necessity and appropriateness of care for benefits requested and/or rendered.Work with clinical support staff to ensure service requests, authorizations and/or grievances are managed in accordance with state and federal guidelines.Identify and refer potential quality of care issues for peer review.Ensure that authorization decisions are based on organizational policy and state and federal coverage rules.Gather and submit documents for third party case review; this includes all documentation and follow-up activities.Issue denial notices based on established unit protocols and state and/or federal requirements. Assist with periodic audits, general quality management and improvement activities, and other regulatory activities as needed.Foster collaboration with teams across the Clinical Operations department to ensure work and goals are met.Meet or exceed department production, timelines, and quality standards established for level I.May participate in departmental workgroups or projects as assigned.Support testing for system updates and implementations as assigned.May help train new staff and teammates as assigned.Cross train in additional functional focus areas as assigned.Duties Specific to Functional Focus AreaBenefit ManagementReview provider pre-service requests and determine benefit coverage according to Medicare, Medicaid and/or organizational guidelines.Benefit ReviewDetermine appropriate level of care and length of stay for inpatient members to include hospitals, skilled nursing facilities, long term acute care hospitals, inpatient rehabilitation hospitals, and respite care programs.Review inpatient admission for re-insurance clinical reporting.Appeals and GrievanceAssemble evidence and build clinical cases for administrative hearings or Independent Review Entity (IRE) reviews.Function as a CareOregon representative in administrative hearings.Assist with the analysis and summary of data for written reports and public presentations as needed.Communicate with members, providers, health plan administrators to manage grievances and appeals and provide case status updates as needed.Investigate and use clinical judgement to identify quality of care or safety issues and present findings to an oversight committee.Health Related ServicesReview provider and member submitted HRSN and Flexible Services requests and determine benefit eligibility according to Medicaid and/or organizational guidelines.Experience and/or EducationRequiredCurrent unrestricted Oregon RN licenseMinimum 2 years RN experience [OR 1 year RN experience AND 3 years’ experience in healthcare setting role(s) such as billing, coding, medical assistant, etc.]PreferredMore than 1 year RN experienceHealthcare utilization management experience in the functional focus area (Appeals and Grievance, Benefits Review or Benefit Management)Experience with Medicaid and/or Medicare utilization managementKnowledge, Skills and Abilities RequiredKnowledgeKnowledge of Medicaid health plan and Medicare benefitsKnowledge of applicable DMAP rules and regulationsKnowledge of ICD-10, CPT, and HCPCS codesFamiliarity with the principles of utilization managementFamiliarity with healthcare documentation systemsSkills and AbilitiesGeneral computer skills including use of Microsoft Office applications and internet search functionsAbility to use review criteria in accordance with departmental policiesAbility to adhere to HIPAA regulations e.g., maintaining confidentiality of protected health informationAbility to interpret and apply complex policies and proceduresAbility to review work for accuracyAbility to independently prioritize workAbility to use critical thinking and problem-solving skillsStrong spoken and written communication skillsStrong interpersonal and customer service skillsAbility to work effectively with diverse individuals and groupsAbility to learn, focus, understand, and evaluate information and determine appropriate actionsAbility to accept direction and feedback, as well as tolerate and manage stressAbility to see, read, and perform repetitive finger and wrist movement for at least 6 hours/dayAbility to hear and speak clearly for at least 3-6 hours/dayWorking ConditionsWork Environment(s): Indoor/Office Community Facilities/Security Outdoor ExposureMember/Patient Facing: No Telephonic In PersonHazards: May include, but not limited to, physical and ergonomic hazards.Equipment: General office equipmentTravel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.Work Location: Work from homeWe offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.We are an equal opportunity employerCareOregon is an equal opportunity employer. The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.