Registered Nurse / RN – Utilization Management I

🕒 July 1

🌲 Oregon – Remote

🌲 Oregon – Remote

💵 $102.3k - $125.1k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

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CareOregon

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1994

🏥 Healthcare

📦 Logistics

🛡️ Insurance

Healthcare • Logistics • Insurance

CareOregon is a community-focused health plan that provides coordinated physical, behavioral, dental and social-support services to Oregon Health Plan members, serving more than 500,000 people. The organization operates provider and member portals, offers care coordination, telehealth, language and tribal services, community grants and outreach, and programs addressing social determinants of health such as housing, nutrition and transportation.

📋 Description

• 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

🎯 Requirements

• 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.] • 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 the principles of utilization management • Familiarity with healthcare documentation systems • General computer skills including use of Microsoft Office applications and internet search functions • Ability to use review criteria in accordance with departmental policies • Ability to adhere to HIPAA regulations e.g., maintaining confidentiality of protected health information • Ability to interpret and apply complex policies and procedures • Ability to review work for accuracy • Ability to independently prioritize work • Ability to use 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, as well as tolerate and manage stress • Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day • Ability to hear and speak clearly for at least 3-6 hours/day

🏖️ Benefits

• Medical, dental, vision, life, AD&D, and disability insurance • Health savings account • Flexible spending account(s) • Lifestyle spending account • Employee assistance program • Wellness program • Discounts • Multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings) • Strong retirement plan with employer contributions • PTO and Paid State Sick Time based on hours worked/scheduled hours