Job Description

Summary

This position plays a crucial role in delivering efficient and high-quality utilization management services, leveraging clinical expertise to achieve optimal clinical and financial outcomes.

Essential Duties

Conducts clinical reviews to ensure cost containment and appropriate service utilization.
Makes service determinations based on member benefits and clinical criteria.
Collaborates with discharge planners to facilitate safe and timely discharges through concurrent reviews.
Uses resources effectively to manage costs.
Identifies members who could benefit from Care Coordination and initiates internal referrals.
Monitors workflow queues to ensure timely processing of service determinations within government-mandated timeframes.
Researches and applies federal, state, and health plan criteria for service determinations.
Identifies complex cases and presents them at Complex Care Team meetings.
Identifies workflow deficiencies and proposes solutions for improvement.
On Call Responsibilities

This position involves intermittent on-call duties.

Education & Experience

Bachelor's degree (BA) from a four-year college or university; or one to two years of related experience and/or training, or an equivalent combination of education and experience.
Minimum of two years of experience in utilization management, managed care, or home care coordination.
Knowledge of CPT codes, HEDIS, HIPAA, ICD-10 codes, Medicare guidelines, NCQA standards, and coordination of benefits (e.g., Worker's Compensation, Auto Insurance, Short and Long Term Disability).
Familiarity with appropriate referrals to Ethics Committee, Corporate Compliance, Fraud and Abuse, or Legal Services.
Preferred knowledge of billing and claims processing.
Certificates, Licenses and/or Registrations

Current Oregon Registered Nursing License, without restrictions or pending disciplinary actions, allowing independent practice.
Physical Demands & Work Environment

Occasionally lifts and/or moves up to 10 pounds.
Regularly sits; uses hands to handle, feel, or operate objects, tools, or controls; and communicates effectively.
Occasionally stands, walks, and reaches with hands and arms.
Moderate noise level in the work environment.
Able to work onsite for all scheduled shifts and from a home office for scheduled shifts as needed and approved.
Employment Type: Full-Time
Salary: $ 20.00 40.00 Per Hour

Job Tags

Hourly pay, Full time, Temporary work, Home office, Shift work, All shifts,

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