[Hiring] Registered Nurse / RN - Utilization Management I @CareOregon

Role Description

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 position focuses on Appeals and Grievance.

Estimated Hiring Range: $102,330.00 - $125,070.00

Bonus Target: Bonus - SIP Target, 5% Annual

Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.

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) such as billing, coding, medical assistant, etc.
• More than 1 year RN experience (preferred)
• Healthcare utilization management experience in the functional focus area (Appeals and Grievance, Benefits Review or Benefit Management) (preferred)
• Experience with Medicaid and/or Medicare utilization management (preferred)

Requirements

• Communicate 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.

Benefits

• Competitive pay
• Bonus opportunity
• Comprehensive benefits package including medical, dental, vision, life, AD&D, and disability insurance
• Health savings account, flexible spending account(s), lifestyle spending account
• Employee assistance program and 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.)
• Strong retirement plan with employer contributions
• PTO and Paid State Sick Time based on hours worked/scheduled hours
• Paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility
• 401(k) contributions for non-benefits eligible employees