Remote RN: Utilization Management & Appeals

Working Conditions Work Environment: Indoor/Office, Community, Facilities/Security, Outdoor Exposure. Member/Patient Facing: No. Hazards: Physical and ergonomic hazards. Equipment: General office equipment. Travel: Occasional required or optional travel outside the workplace; personal vehicle, local transit or other means of transportation may be used. Work Location: Work from home. Estimated Hiring Range $102,330.00 – $125,070.00 Bonus Target Bonus – SIP Target, 5% Annual. Essential Responsibilities General Duties 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. Required Experience and/or Education Current unrestricted Oregon RN license. Minimum 2 years RN experience [or 1 year RN experience and 3 years’ experience in healthcare setting roles 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 movements for at least 6 hours/day. Ability to hear and speak clearly for at least 3–6 hours/day. We Are an Equal Opportunity Employer CareOregon is 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. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization. #J-18808-Ljbffr