Utilization Review

Job TitleSamaritan Health Plans (SHP) provides health insurance options to Samaritan employees, community employers, and Medicare and Medicaid members. SHP operates a portfolio of health plan products under several different legal structures: InterCommunityHealth Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans.As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services' mission of Building Healthier Communities Together.This is a remote position in which we are able to employ in the following states: Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin.Our ideal candidate will have the following experience:Health plan utilization managementMedicare and Medicaid rules and regulations and health plan benefit structure and policy.Data analysis to include reporting results and developing improvement plansQuality Management experience in a healthcare settingJob Summary/PurposeExecutes program(s) that meet the needs of the organization, employees and/or customers. Plans, initiates, oversees execution of all elements for assigned program(s). Leads the development, implementation and management of assigned program(s) and associated projects. Oversees process from planning to completion. Works with multiple internal teams, vendors, clients. Responsible for explaining, training, and mentoring the entire organization on the program. Collaborates with SHS system experts to ensure focus, alignment, and best practices for the program.Experience/Education/QualificationsCurrent unencumbered Oregon RN License required within 90 days of hire. BSN preferred. Master's degree in a related field preferred.One (1) year clinical nursing experience plus four (4) years health plan utilization management experience required.Experience or training in the following required:Health care delivery systems and/or managed care patients.Computer applications including electronic documentation (e.g., MS Office, EPIC, Clinical Care Advanced).Experience in the following preferred:Team leadership.Case management.Medicare and Medicaid rules and regulations and health plan benefit structure and policy.Knowledge/Skills/AbilitiesLeadership - Inspires, motivates, and guides others toward accomplishing goals. Achieves desired results through effective people management.Conflict resolution - Influences others to build consensus and gain cooperation. Proactively resolves conflicts in a positive and constructive manner.Critical thinking – Identifies complex problems. Involves key parties, gathers pertinent data and considers various options in decision making process. Develops, evaluates and implements effective solutions.Communication and team building – Lead effectively with excellent verbal and written communication. Delegates and initiates/manage cross-functional teams and multi-disciplinary projects.