BMPS RN

AllCare Management Services•Grants Pass, OR

36d

About The Position

This position is responsible for providing efficient and quality utilization management services utilizing clinical knowledge to support achieving optimal clinical and financial outcomes by performing the following duties.

Requirements

One-year certificate from college or technical school in LPN (For LPN only)
Associate's degree (AA) from a two-year college or technical school in nursing.
Two to four years related experience and/or training in utilization management, managed care, inpatient care or home care coordination.
Valid Oregon Driver’s License and vehicle insurance If employee resides in Jackson or Josephine County
Valid Oregon LPN, RN Licensure free of any restrictions or disciplinary action pending, and able to legally and independently practice without the supervision of another licensed professional.
Knowledge of CPT codes, HEDIS, HIPAA, ICD-10 codes, Medicare guidelines, NCQA, Coordination of benefits where applicable (i.e. Worker’s Compensation, Auto Insurance, Short- and Long-Term Disability), appropriate referrals to Corporate Compliance, Fraud and Abuse or Legal Services is required.
Familiarity with the Healthcare industry.
Exceptional writing, editing, and proofreading skills.
Excellent organization and time-management skills.
Excellent computer skills, including the Microsoft Office Suite (Outlook, Word, PowerPoint, and Excel).
Knowledge of and compliance with HIPAA regulations.
Excellent at identifying and implementing improvement activities and ensuring excellence.
Excellent at interpreting data and using it to solve problems and gain new insights.
Excellent at locating information and synthesizing information from various sources.
Knowledge of the ways implicit bias, personal identity, and power and privilege impact individuals, organizations and systems.
Demonstrate accountability, inspiring trust and confidence from others.
Self-resolve most conflicts or misunderstandings with minimal need for direct supervision.
Work with high initiative, energy and effectiveness in a fast-past environment.
Effectively and professionally communicate with team members.
Collaborate within a multidisciplinary, diverse team to provide professional service.
Prioritize and organize work according to competing timelines.
Allocate your time so that you can complete tasks within established deadlines.
Adapt to change, learn quickly, and work with ambiguity.
Use creativity and resourcefulness to solve new problems.
Cope and self-manage during stressful situations.
Maintain an attentive and empathetic demeanor.
Maintain a high degree of professionalism and confidentiality.
Create a pleasant experience for all customers, such as being personable and attentive.
Meet timelines for goals safely and with high level of quality.
Make decisions independently in accordance with established policies and procedures.
Take initiative and apply sound judgment in completing tasks and responsibilities.
Examine and shift behaviors, as appropriate.
Commit to being culturally aware.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
Ability to write reports, business correspondence, and procedure manuals.
Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.
Ability to apply concepts of basic algebra and geometry.
Job requires specialized computer skills. Must be adept at using various applications including database, spreadsheet, report writing, project management, graphics, word processing, presentation creation/editing, communicate by e-mail and use scheduling software.
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form.
Ability to work with problems involving several concrete variables in standardized situations.
The employee must occasionally lift and/or move up to 10 pounds.
While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
The employee is occasionally required to stand; walk and reach with hands and arms.
The employee must be able to work from a home office for all scheduled shifts.
The employee must be able to travel locally, occasionally.

Nice To Haves

Knowledge of billing and claims processing preferred.
Being bilingual in another language, including American Sign Language (ASL), is an invaluable skill that enhances our ability to deliver culturally responsive care. We strongly encourage you to apply if you are bilingual.

Responsibilities

Performs clinical review for cost containment and appropriate utilization of services.
Processes service determinations based on member benefits and clinical criteria within designated decision-making scope.
Conducts concurrent reviews and collaborates with discharge planners for appropriate and safe discharge outcomes.
Verifies member eligibility, benefits, and coverage requirements and applies to service determination reviews.
Monitors workflow queues for service determinations to ensure processed within required government timeframe.
Makes service determinations based on medical appropriateness, utilizing applicable criteria, and guidelines.
Identify Stoploss cases and reports as designated per policy.
Identifies members that would benefit from a referral to Care Coordination and initiate internal referrals.
Researches and locates applicable federal and/or state criteria and/or health plan policies for service determinations.
Identifies complex cases, prepares, and presents case file to Complex Care Team meetings.
Utilizes resources in a cost-effective manner.
Identifies workflow deficiencies and recommends solutions to improve.
Communicates effectively with all company staff-.
Oversees problems to their resolution within compliance timeframes and identifies ‘report up’ when necessary.
Works efficiently both independently and in a team environment.
Adheres to workflows to maximize workflow processes.
Changes direction quickly and anticipates the requirements of the day.
Participates in peer review audits to assist in identifying quality improvement initiatives and offers suggestions for improvement in the review process.
Builds a collaborative relationship and maintain a courteous and professional manner at all times with providers and other health care staff at all times.
Reports quality of care issues identified during the utilization management review process.
Maintains punctual, regular, and predictable attendance.
Respectfully takes direction from leadership.
Meets all required training including those listed in Relias Learning Module System (LMS).
Other duties as assigned.