Remote RN: Utilization Management (Appeals & Grievances)

CareOregon, Inc.; Oregon; Hybrid; USD 102,000 - 125,000; Full time

Benefits offered by this job

Bonus opportunity

Benefits package

Retirement plan

PTO

Paid holidays

Job summary

CareOregon, Inc. is seeking a Registered Nurse - Utilization Management I to support UM program functions within Clinical Operations.

This remote role focuses on Benefit Management, Benefit Review, Appeals and Grievances, and Health Related Services, ensuring medically appropriate decisions while managing costs. Candidates must hold an Oregon RN license and have 2 years RN experience (or 1 year RN plus 3 years healthcare experience).

Qualifications

• Current unrestricted Oregon RN license.
• Minimum 2 years RN experience OR 1 year RN experience AND 3 years’ experience in healthcare setting role(s).
• Preferred: more than 1 year RN experience.
• Healthcare utilization management experience in Appeals and Grievance, Benefits Review or Benefit Management preferred.
• Experience with Medicaid and/or Medicare utilization management preferred.

Responsibilities

• Communicate with members and providers professionally per state and federal requirements.
• Maintain confidentiality of all data in quality management activities.
• Refer members to care coordination per policies.
• Maintain accurate and complete documentation.
• Collaborate with Medical Directors to determine medical necessity and appropriateness of care.
• Work with clinical support staff to manage authorizations and grievances per guidelines.
• Identify and refer potential quality of care issues for peer review.
• Ensure authorization decisions follow organizational policies and regulatory rules.

Skills

RN license Oregon

Healthcare experience

Communication skills

HIPAA compliance

Job description

CareOregon, Inc. is seeking a Registered Nurse - Utilization Management I to support UM program functions within Clinical Operations.

This remote role focuses on Benefit Management, Benefit Review, Appeals and Grievances, and Health Related Services, ensuring medically appropriate decisions while managing costs. Candidates must hold an Oregon RN license and have 2 years RN experience (or 1 year RN plus 3 years healthcare experience).