Job 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.
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.
Duties Specific to Functional Focus Area
Benefit Management: Review provider pre-service requests and determine benefit coverage according to Medicare, Medicaid and/or organizational guidelines.
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.
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.
Assist with the analysis and summary of 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.
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
- Required: 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 the functional focus area (Appeals and Grievance, Benefits Review or Benefit Management)
Experience with Medicaid and/or Medicare utilization management
Knowledge, Skills and Abilities Required
Knowledge: 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
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
Hazards: May include, but not limited to, physical and ergonomic hazards.
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
About CareOregon
CareOregon is a nonprofit, mission-driven health plan, focused on providing care to low-income Oregonians. The CareOregon family includes Columbia Pacific CCO, Jackson Care Connect, Housecall Providers and our work as part of Health Share of Oregon. We also support recruitment for the Oregon Health and Education Collaborative.
