Registered Nurse / RN - Utilization Management I

About the role

The Registered Nurse - Utilization Management I supports 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).

Responsibilities

• 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.

Functional Focus Area: Benefit Management

• Review provider pre-service requests and determine benefit coverage according to Medicare, Medicaid and/or organizational guidelines.

Functional Focus Area: Benefit Review

• Determine appropriate level of care and length of stay for inpatient members to include hospitals, skilled nursing facilities, long term acute care hospitals, inpatient rehabilitation hospitals, and respite care programs.
• Review inpatient admission for re-insurance clinical reporting.

Functional Focus Area: Appeals and Grievance

• Assemble evidence and build clinical cases for administrative hearings or Independent Review Entity (IRE) reviews.
• Function as a CareOregon representative in administrative hearings.
• Absorb data for written reports and public presentations as needed.
• Communicate with members, providers, health plan administrators to manage grievances and appeals and provide case status updates as needed.
• Investigate and use clinical judgement to identify quality of care or safety issues and present findings to an oversight committee.

Functional Focus Area: Health Related Services

• Review provider and member submitted HRSN and Flexible Services requests and determine benefit eligibility according to Medicaid and/or organizational guidelines.

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.].

Preferred

• More than 1 year RN experience
• Healthcare utilization management experience in Prior Authorization UM
• Experience with Medicaid and/or Medicare utilization management
• Knowledge of ICD-10, CPT, and HCPCS codes
• Familiarity with the principles of utilization management
• Familiarity with healthcare documentation systems

Skills and Abilities

• 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

Working Conditions

• Work Environment(s): Indoor/Office
• Member/Patient Facing: No
• Equipment: General office equipment
• Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.
• Work Location: Work from home

Benefits

• We offer a strong Total Rewards Program including competitive pay, bonus opportunity, and a comprehensive benefits package.
• Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state.
• We also offer a strong retirement plan with employer contributions.

Equal Opportunity Employer

We are an equal opportunity employer. The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability.