Remote Registered Nurse – Utilization Management I

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

Job summary

CareOregon, Inc. is seeking a Registered Nurse - Utilization Management I to support UM program functions within Clinical Operations, including Benefit Management, Benefit Review, Appeals and Grievances, and Health Related Services.

The role helps determine medically appropriate services using clinical criteria while managing medical expenses. This is a remote position with preference for candidates in Oregon and SW Washington.

Qualifications

• Current unrestricted Oregon RN license.
• Minimum 2 years RN experience OR 1 year RN + 3 years in healthcare setting roles such as billing, coding or medical assistant.
• Preferred RN experience in utilization management and Appeals/Grievances.
• Experience with Medicaid/Medicare utilization management is a plus.
• Ability to apply clinical criteria and maintain documentation.

Responsibilities

• Communicate with members/providers professionally per state/federal requirements.
• Maintain confidentiality of information per HIPAA and quality standards.
• Refer members to care coordination per policies and procedures.
• Collaborate with Medical Directors to determine medical necessity and appropriateness of care.
• Ensure authorizations and grievances are managed per guidelines.
• Assist with audits and quality improvement activities.

Skills

HIPAA compliance

Strong communication

Critical thinking

Documentation

Team collaboration

Education

RN license (Oregon)

Tools

Microsoft Office

Job description

CareOregon, Inc. is seeking a Registered Nurse - Utilization Management I to support UM program functions within Clinical Operations, including Benefit Management, Benefit Review, Appeals and Grievances, and Health Related Services.

The role helps determine medically appropriate services using clinical criteria while managing medical expenses. This is a remote position with preference for candidates in Oregon and SW Washington.