Registered Nurse - Utilization Management I

CareOregon • Portland, OR

1d • $102,330 - $125,070 • Remote

About The Position

The Registered Nurse - Utilization Management I supports utilization management program functions within the Clinical Operations department. These functions include Benefit Management, Benefit Review, Appeals and Grievances, and Health Related Services. The programs support members’ healthcare needs, determine medically appropriate services, apply clinical-based criteria for decision-making, and manage medical expenses. This position is on the Appeals and Grievances team and works from home. Candidates residing in Oregon and Southwest Washington are preferred.

The role communicates with members, providers, and health plan administrators; collaborates with Medical Directors and clinical support staff; reviews coverage, medical necessity, and appropriateness of care; and maintains accurate, confidential documentation. The RN may contribute to audits, quality improvement and regulatory activities, projects, system testing, training, and cross-training. The position may require occasional travel outside the workplace.

The estimated hiring range is $102,330–$125,070, with a 5% annual SIP bonus target. CareOregon offers a comprehensive rewards and benefits program, subject to eligibility and position type.

Requirements

• Current unrestricted Oregon RN license.
• At least 2 years of RN experience, or 1 year of RN experience and 3 years of experience in healthcare setting roles such as billing, coding, or medical assisting.
• Knowledge of Medicaid health plan and Medicare benefits.
• Knowledge of applicable DMAP rules and regulations.
• Knowledge of ICD-10, CPT, and HCPCS codes.
• Familiarity with utilization management principles.
• Familiarity with healthcare documentation systems.
• General computer skills, including Microsoft Office applications and internet search functions.
• Ability to use review criteria in accordance with departmental policies.
• Ability to adhere to HIPAA regulations and maintain confidentiality of protected health information.
• Ability to interpret and apply complex policies and procedures.
• Ability to review work for accuracy and independently prioritize work.
• Critical-thinking and problem-solving skills.
• Strong spoken and written communication skills.
• Strong interpersonal and customer service skills.
• Ability to work effectively with diverse individuals and groups.
• Ability to learn, focus, understand, and evaluate information and determine appropriate actions.
• Ability to accept direction and feedback and tolerate and manage stress.
• Ability to see, read, and perform repetitive finger and wrist movements for at least 6 hours per day.
• Ability to hear and speak clearly for at least 3–6 hours per day.

Nice To Haves

• More than 1 year of RN experience.
• Healthcare utilization management experience in Appeals and Grievances, Benefit Review, or Benefit Management.
• Experience with Medicaid and/or Medicare utilization management.

Responsibilities

• Communicate professionally with members and/or providers, as needed, in accordance with state and federal requirements.
• Maintain confidentiality of discussions, records, and other data related to quality management activities.
• Refer members to care coordination according to policies and procedures.
• Maintain accurate and complete documentation.
• Collaborate with Medical Directors to determine medical necessity and appropriateness of care for requested or rendered benefits.
• Work with clinical support staff to ensure service requests, authorizations, and grievances are handled in accordance with state and federal guidelines.
• Identify and refer potential quality-of-care issues for peer review.
• Ensure authorization decisions follow organizational policy and state and federal coverage rules.
• Gather and submit documents for third-party case review, including required documentation and follow-up.
• Issue denial notices according to established unit protocols and state and/or federal requirements.
• Assist with periodic audits, quality management and improvement activities, and other regulatory activities as needed.
• Collaborate with teams across Clinical Operations to meet work objectives and goals.
• Meet or exceed department production, timeline, and quality standards for level I.
• Participate in departmental workgroups or projects as assigned.
• Support testing for system updates and implementations as assigned.
• Help train new staff and teammates as assigned.
• Cross-train in additional functional focus areas as assigned.
• For Benefit Management, review provider pre-service requests and determine benefit coverage according to Medicare, Medicaid, and/or organizational guidelines.
• For Benefit Review, determine appropriate level of care and length of stay for inpatient members in hospitals, skilled nursing facilities, long-term acute care hospitals, inpatient rehabilitation hospitals, and respite care programs.
• For Benefit Review, review inpatient admissions for reinsurance clinical reporting.
• For Appeals and Grievances, assemble evidence and build clinical cases for administrative hearings or Independent Review Entity reviews.
• For Appeals and Grievances, represent CareOregon in administrative hearings.
• Assist with analysis and summary of data for written reports and public presentations as needed.
• Communicate with members, providers, and health plan administrators to manage grievances and appeals and provide case status updates as needed.
• Investigate and use clinical judgment to identify quality-of-care or safety issues and present findings to an oversight committee.
• For Health Related Services, review provider- and member-submitted HRSN and Flexible Services requests and determine benefit eligibility according to Medicaid and/or organizational guidelines.

Benefits

• Competitive pay and bonus opportunity.
• Medical, dental, vision, life, AD&D, and disability insurance.
• Health savings account, flexible spending accounts, and lifestyle spending account.
• Employee assistance program and wellness program.
• Discounts and supplemental benefits, including voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, and 529 College Savings.
• Retirement plan with employer contributions.
• PTO and Paid State Sick Time for benefits-eligible employees, accrued based on hours worked or scheduled hours and primary work state.
• Paid holidays, volunteer time, jury duty, bereavement leave, and other leave depending on eligibility.
• For non-benefits-eligible employees: 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed