Registered Nurse - RN - Utilization Management

Utilization Management Registered NurseDepartment: Medical ManagementTitle of Manager: Utilization Management ManagerSupervises: Non-supervisory positionEmployment Status: Regular – Non-ExemptWork Hours: Monday – Friday, 8:00 AM – 5:00 PM General Statement of Duties The utilization management (UM) registered nurse (RN) is responsible for supporting the UM functions within the department. These UM functions include processing referral and authorization requests, performing concurrent review and processing service appeal denials. The UM RN may not routinely perform all essential functions on a daily basis. However, the expectation is that the UM RN will have the basic knowledge and skills to perform all the tasks during times of coverage needs or reassignment of work. Essential Position FunctionsReferrals and Prior Authorizations-Review request to determine if needed information has been provided and request additional information as needed-Process all Level 2 service requests according to the OHP benefit, established protocols, review criteria and sound clinical judgment-Submit questionable service requests to Chief Medical Officer -Issue denial notices based on established unit protocolsConcurrent Review-Review medical information and make authorization decisions based on review criteria and sound clinical judgment-Review facility stays with Chief Medical Officer during regularly scheduled unit rounds-Review questionable stays requiring immediate action with Chief Medical Officer on a daily basis-Work with facility discharge planner to assist in discharge planning needs for problematic discharges-Negotiate fee schedule for unusual situations after consultation with Chief Medical Officer and as deemed appropriate, Unit Manager and/or Director of Provider Relations Department Service Denial Appeals-Obtain all information needed to process appeal request-Gather, analyze and assemble the documents-Process appeal request based on established unit protocols-Document Utilization Management Appeal cases according to established guidelines-Issue decision notices based on established unit protocols Essential Department and Organizational Functions-Process service requests according to established timelines, including claim issues-Forward to the Care Coordinator RN, or CareOregon Behavioral Health staff, members who require follow-up according to established unit protocols-Screen situations to determine if OMAP disenrollment criteria applies and request disenrollment according to the unit protocols -Provide training to new employees on specific tasks related to their job responsibilities-Follow established departmental policies and procedures-Report to work as scheduled-Perform other duties and projects as assigned Knowledge, skills and abilities required-Knowledge of the Oregon Health Plan and Medicare A and B benefit packages-Ability to use review criteria (Interqual and Milliman; Robertson)-Knowledge of OMAP rules and regulations as it pertains to utilization management and disenrollment criteria-Knowledge of ICD-9, CPT and HCPCS codes-Ability to collaborate with community providers including facility staff -Familiarity with the principles of managed care and utilization management -Ability to use critical thinking skills in problem solving-Ability to write and verbally communicate effectively -Excellent customer service skills-Ability to work in an environment with diverse individuals and groups-Ability to manage multiple tasks-Ability to work autonomously-Basic word processing skills-Valid driver's licenseEducation and/or ExperienceCurrent Oregon RN license required. One (1) year experience in utilization management functions preferred. Preference may be given to individuals with UM experience administrating the Oregon Health Plan benefit.Working ConditionsThis individual will experience answering a lot of phone calls, completing worksheets, and using computer programs to either obtain or record information. These functions will occur on an on-going basis and will need to be performed simultaneously.This individual will be expected to possess a high degree of initiative and motivation along with the ability to effectively collaborate and plan with coworkers and others. In addition, this individual will be in contact with a variety of professional and technical staff and must be customer service oriented and able to function under potentially tight time lines. Attention to detail is critical for accuracy and timeliness of processing service requests. Given the multiple tasks and deadlines, this individual must be able to organize their work and remain focused under stressful conditions. This position will require an individual to sit for long periods of time. This position may For more information about our job opportunities, please visit our website. http://www.maximstaffing.comCurrent Oregon RN license required. One (1) year experience in utilization management functions preferred. Preference may be given to individuals with UM experience administrating the Oregon Health Plan benefit. Job Title: Registered Nurse - RN - Utilization Management Company: Maxim Staffing Solutions--Nurse Staffing Location: Portland, OR 97201 Status: Employee Job Category: Medical/Health Contact: Alec Fisher Email: Apply by Email Address: MD 21046 Phone: 866-492-5629 Fax: 916-614-9547 Reference Code: 72197