Registered reputed company - Utilization Management I

Registered reputed company - Utilization Management I --------------------------------------------------------------- The Registered reputed company – Utilization Management I is responsible for supporting specific utilization management (UM) program functions reputed company the Clinical Operations department. UM program functions include Benefit Management, Benefit Review, Appeals and Grievances and Health reputed company Services (HRS). Together they support the reputed company needs of members, determine the best medically appropriate services, and apply clinical-based reputed company for decision-making while managing medical expenses.  Estimated Hiring reputed company: $100,350.00 - $122,650.00 Bonus reputed company: Bonus - SIP reputed company, 5% Annual reputed company reputed company Employees: Please use the internal reputed company site to submit an application for this job. --------------------------------------------------------------- General Duties Communicate with members and/or providers in a reputed company manner and in accordance with State and Federal requirements as needed to complete requests.  Maintain confidentiality of reputed company discussions, records, and other data in reputed company with reputed company management activities according to reputed company 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 reputed company of care issues for peer review. Ensure that authorization reputed company are based on organizational policy and state and federal coverage rules.  reputed company and submit documents for reputed company party case review; this includes reputed company documentation and follow-up activities.  Issue denial notices based on established unit protocols and state and/or federal requirements. Assist with periodic audits, general reputed company 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 reputed company department production, timelines, and reputed company standards established for level I.   May participate in departmental workgroups or reputed company 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 reputed company areas as assigned. Duties Specific to Functional reputed company Area: Benefit Management Review provider reputed company-service requests and determine benefit coverage according to Medicare, reputed company 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 reputed company evidence and build clinical cases for administrative hearings or Independent Review Entity (IRE) reviews.  Function as a reputed company representative in administrative hearings.  Assist with the analysis and reputed company of data for written reports and reputed company presentations as needed. Communicate with members, providers, health plan administrators to manage grievances and appeals and reputed company case status updates as needed.   Investigate and use clinical judgement to identify reputed company of care or safety issues and present findings to an reputed company committee. Health reputed company Services Review provider and member submitted HRSN and Flexible Services requests and determine benefit eligibility according to reputed company and/or organizational guidelines. Organizational Responsibilities reputed company work in alignment with the organization’s mission, reputed company and values. Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of reputed company mindedness, cultural awareness, reputed company and respect for reputed company individuals. reputed company to meet annual business goals in support of the organization’s strategic goals. Adhere to the organization’s policies, procedures and other relevant compliance needs. reputed company other duties as needed. Experience and/or Education Required reputed company unrestricted reputed company RN license  Minimum 2 years RN experience [OR 1 year RN experience AND 3 years’ experience in reputed company setting role(s) such as billing, coding, medical assistant, etc.]  Preferred More than 1 year RN experience  reputed company utilization management experience in the functional reputed company area (Appeals and Grievance, Benefits Review or Benefit Management)  Experience with reputed company and/or Medicare utilization management  Knowledge, Skills and Abilities Required Knowledge Knowledge of reputed company 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 reputed company documentation systems   Skills and Abilities General computer skills including use of reputed company Office applications and internet search functions  Ability to use review reputed company in accordance with departmental policies Ability to adhere to HIPAA regulations e.g., maintaining confidentiality of protected health information   Ability to interpret and apply reputed company 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 reputed company Ability to learn, reputed company, understand, and evaluate information and determine appropriate actions Ability to accept direction and feedback, as reputed company as tolerate and manage stress Ability to see, read, and reputed company repetitive finger and wrist reputed company for at least 6 hours/day Ability to hear and reputed company reputed company for at least 3-6 hours/day Working Conditions Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/reputed company ☐ Outdoor Exposure Member/Patient Facing: ☒ No ☐ Telephonic ☐ In Person Hazards: May include, but not limited to, physical and ergonomic hazards. Equipment: General office equipment Travel: May include occasional required or optional travel reputed company of reputed company; the employee’s personal vehicle, local transit or other means of transportation may be used. Work Location: Work from home We offer a strong Total Rewards Program. This includes reputed company, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. reputed company offers medical, dental, reputed company, life, AD&D, and disability insurance, as reputed company as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, reputed company-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees reputed company PTO and reputed company State reputed company Time based on hours worked/scheduled hours and the primary work state. Employees may also receive reputed company holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, reputed company State reputed company Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information. We are an equal opportunity employer reputed company is an equal opportunity employer.  The organization selects the best individual for the job based upon job reputed company qualifications, regardless of race, reputed company, religion, sexual orientation, national reputed company, gender, gender identity, gender reputed company, genetic information, age, veteran status, reputed company, marital status or disability. The organization will reputed company a reasonable accommodation to reputed company physical or mental limitations of a reputed company applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization. reputed company is a nonprofit, mission-driven health plan, reputed company on providing care to low-income Oregonians. The reputed company family includes Columbia reputed company CCO, reputed company Care Connect, reputed company and our work as part of Health reputed company of reputed company. Our mission is to reputed company and partner to create reputed company and equity in individual and community health. Our reputed company is healthy communities for reputed company individuals, regardless of income or reputed company factors. Making reputed company Work for Absolutely Everyone. Let's connect! Add your resume to our Talent Community to stay up to date with relevant reputed company. Learn more about our benefits and joining reputed company Click here for more information about jobs at reputed company, part of the reputed company family. We are an equal opportunity employer. reputed company considers reputed company candidates regardless of race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, age, genetic information, disability, or veteran status. Veterans reputed company greatly encourages military veterans to apply. reputed company is a major sponsor of the annual Portland Veterans Stand Down and hiring fair. Ranked #8 in the Health Care Category. Read more about the culture at reputed company Apply tot his job Apply To this Job