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Form of workWe are currently hiring a REMOTE Utilization Review Nurse! If you are a licensed nurse with excellent critical thinking skills, have experience in acute care settings and Utilization Review, and value being part of a team that makes a difference, you may be the right person for the position! Apply today!
JOB SPECIFICATIONS
Classification: NON-EXEMPT
Status: Full-Time, Monday - Friday, generally 8am to 5pm, Pacific Time
Salary: $33.26 - $42.77/HOURLY
Department: Medical Services/Utilization Review
JOB SPECIFICATIONS
Classification: NON-EXEMPT
Status: Full-Time, Monday - Friday, generally 8am to 5pm, Pacific Time
Salary: $33.26 - $42.77/HOURLY
Department: Medical Services/Utilization Review
Work Location: OR, WA, CA, AZ, NV, WY, TX, GA, FL, AL
Reports to: Director of Medical Services
Supervision Exercised: Non-Supervisory
JOB PURPOSE: Utilization Review Nurse
The Clinical Review Nurse is responsible for providing clinically efficient and effective utilization management. Reviews prior authorization requests for appropriate care and setting by following evidence based clinical guidelines, medical necessity criteria and health plan guidelines. Reviews and applies hierarchy of criteria to all referral and preauthorization requests from the PCP's and specialists that require a medical necessity determination. Is involved in assuring that the patient receives high-quality cost-effective care. Uses sound clinical judgement and Managed Care principles in the coordination of care. Prepares any case that does not meet medical necessity guidelines for medical appropriateness of procedure, service, or treatment for review with the Physician Reviewer for a decision.
QUALIFICATIONS, EDUCATION, and EXPERIENCE
Reports to: Director of Medical Services
Supervision Exercised: Non-Supervisory
JOB PURPOSE: Utilization Review Nurse
The Clinical Review Nurse is responsible for providing clinically efficient and effective utilization management. Reviews prior authorization requests for appropriate care and setting by following evidence based clinical guidelines, medical necessity criteria and health plan guidelines. Reviews and applies hierarchy of criteria to all referral and preauthorization requests from the PCP's and specialists that require a medical necessity determination. Is involved in assuring that the patient receives high-quality cost-effective care. Uses sound clinical judgement and Managed Care principles in the coordination of care. Prepares any case that does not meet medical necessity guidelines for medical appropriateness of procedure, service, or treatment for review with the Physician Reviewer for a decision.
QUALIFICATIONS, EDUCATION, and EXPERIENCE
- Nursing degree from an accredited nursing program
- Unrestricted Oregon RN license
- Experience with a similar population in health plans or Managed Care
- Experience administering OHP, Medicare benefits or Utilization Review highly preferred.
ESSENTIAL RESPONSIBILITIES: Licensed Utilization Review
- Maintains clinical expertise and knowledge of scientific progress in nursing and medical arena and incorporates this information into the clinical review and care coordination processes
- Performs clinical review for appropriate utilization of medical services by applying appropriate medical necessity criteria guidelines
- Authorizes healthcare services in compliance with contractual agreements, Health Plan guidelines and appropriate medical necessity criteria
- Provides accurate and timely documentation within internal system supporting rational of decision based on clinical review
- Identifies members who are appropriate for care coordination programs and collaborates with the Medical Management team for care coordination of the member's needs along the continuum of care
- Meets timeliness standards for referral and prior authorization activities
- Sends appropriate notifications for Third Party Liability (TPL) and/or possible Stop Loss
- Forward relevant information of members requiring special interventions to Advanced Health
- Participate in quality and organizational process improvement activities and teams when requested
- Assist in audit preparation as directed
- Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
- Handle confidential information and materials appropriately and maintains a secure work area
- Maintains the confidentiality of all company procedures, results, and information about patients, contracts, and all other proprietary information regarding company business.
- Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
- Handle confidential information and materials appropriately and maintain a secure work area
- Other duties as assigned
ESSENTIAL RESPONSIBILITIES: ORGANIZATIONAL TEAM MEMBER
- Participate in quality and organizational process improvement activities and teams when requested
- Support and contribute to effective safety, quality, and risk management efforts by adhering to established; policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities
- Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
- Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
- Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer’s expectations
- Recognize new developments and remain current in [position’s expertise] best practice standards and anticipate organizational modifications
- Advance personal knowledge base by pursuing continuing education to enhance professional competence
- Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
- Represent organization at meetings and conferences as applicable
KNOWLEDGE, SKILLS, and ABILITIES
- Knowledge of OHP program requirements, benefit package, eligibility categories, and Oregon Division of Medical Assistance Program (MAP) rules and regulations preferred
- Knowledge of ICD, CPT, and HCPCS codes
- Proficient in Milliman Clinical Guidelines (MCG)
- Strong attention to detail
- Ability to think and work independently with minimum supervision
- Provide critical attention to detail for accuracy and timeliness
- Ability to manage multiple tasks and remain flexible in a dynamic work environment
- Ability to report to work as scheduled, and willingness to work a flexible schedule when needed
- Proficient in Microsoft Office Suite and Windows Operating System (OS)
- Training in or awareness of Health Literacy, Poverty Informed, Systemic Oppression, language access and the use of healthcare interpreters, uses of data to drive health equity, Cultural Awareness, Trauma-Informed Care, Adverse Childhood Experiences (ACEs), Culturally and Linguistically Appropriate Service (CLAS) Standards, and universal access
- Knowledge and understanding of how the positions’ responsibilities contribute to the department and company goals and mission
- Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse
- Awareness and understanding of equity, diversity, inclusion, and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social, political, and environmental contexts of policies, programs, and practices
- Excellent people skills and friendly demeanor
- Critical thinking skills of using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
- Attention to detail and organization skills
- Ability to handle stress and sensitive situations effectively while projecting a professional attitude
- Ability to communicate professionally, both conversing and written
- Ability to work with diverse populations and interact with people of differing personalities and backgrounds
- Sensitive to economic considerations, human needs and aware of how one’s actions may affect others
- Ability to organize and work in a sensitive manner with people from other cultures
- Poised; maintains composure and sense of purpose
WORKING CONDITIONS
This position must have the ability to remain in a stationary position, occasionally move about inside the office to access office machinery, printer, etc., frequently communicate and exchange accurate information.
Work Condition: Remote Work Environment
This position must have the ability to remain in a stationary position, occasionally move about inside the office to access office machinery, printer, etc., frequently communicate and exchange accurate information.
Work Condition: Remote Work Environment
- Employee generally works within a remote work from home environment.
- Travel may be required on occasion.
- Hours of operations and specific staff scheduling may vary based on operational need.
Exposed to:
- Employee is responsible for maintaining a safe work environment that is conducive to successful productivity and work output.
- Machines, equipment, tools, and supplies used: Constantly operates a computer or other office productivity machinery or software, such as fax, copier, calculator, multi-line telephone system, or scanner.
- May answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information.
Multiple Duties: Must be able to work under conditions of frequent interruption and be able to stay on task.
This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of DOCS Management Services employees. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.
This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of DOCS Management Services employees. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.
