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RN Manager, Utilization Management

Portland, OR · Healthcare
Responsibilities: 
  • Manage the operations and support team within Health Care Services including the Call Center, Utilization Management or Care Management intake & review functions which includes but is not limited to prior authorization, concurrent review (CCR), Claims, skilled nursing facility (SNF) Review and care management services.
  • Provide oversight and direction for systems and tools used internally by staff and externally by provider partners to assist in Medical or Care Management operations.
  • Achieves organizational performance standards for Call Center activities, prior authorization, CCR review, SNF review, Claims Audit, Care Management and other areas as deemed appropriate.
  • Prepares and manages budget for applicable area(s).
  • Manages coordination of all work, quality improvement activities, projects, objectives and staffing of the department by working with other Managers and Supervisors within Health Care Services.
  • Evaluates performance and initiates personnel actions such as hiring, merit increases, probationary and periodic reviews, promotions, work plans and disciplinary actions.

Required Qualifications: 
  • Bachelor’s degree in Nursing or other clinical bachelor degree equivalent.
  • Graduate from an accredited school of nursing or graduate from an accredited equivalent clinical program.
  • 3+ years of documented direct management or supervisory experience in a clinical or managed care setting.
  • 5+ years of clinical experience.
  • 2+ years of utilization, quality or care management experience in an insurance or managed care setting.
  • Formal education or training in supervision, management, or leadership and demonstrated experience in program planning, development and evaluation.
  • Proven knowledge of the management, operation, function and objectives of population based utilization and care management services for individual patients/members.
  • Expert customer service skills.
  • Strong project management skills with the ability to coordinate complex projects and build work plans to lead a group through implementation and execution of new projects and continuous process improvement projects.
  • Strong working knowledge of all pertinent regulatory and accrediting body requirements, specifically CMS, State Medicaid Programs, The Affordable Care Act and NCQA.
  • Working knowledge of CPT, HCPCS and ICD-9 & ICD-10 coding.
  • Demonstrated high level computer skills in MS Office Suite, Facets or other claims processing platforms, and Utilization Management or Care Management charting platforms
  • Demonstrated working knowledge of health care cost containment concepts and managed care principles.
  • Knowledge of medical benefits and medical/transplant network administration.
  • Knowledge of confidentiality guidelines.
  • Currently licensed as a registered nurse in good standing in Oregon or current equivalent clinical license.
 
Preferred Qualifications: 
  • Master’s degree in Nursing, or related field.
  • Certification in case management, utilization management or quality improvement.
  • Project management, Six Sigma, Lean, Change Acceleration Process (CAP) experience or certification.
  • Experience with HEDIS, CAHPS, Medicare 5-Star Rating, NCQA and/or URAC accreditation.


Benefits:
  • Medical, dental and vision insurance coverage that start on your first day
  • Retirement program that helps you prepare for your future
  • Life and AD&D insurance
  • Health Reimbursement and Savings Accounts (HRA, HSA, FSA)
  • Health assessment and personal coaching to help you meet your goals
  • Incentives for participation in healthy activities
  • Caregiver Assistance Program (for employees) offering work/life services, resources and expertise when you need it
  • Weight management, tobacco cessation and diabetes programs
  • Volunteers in Partnership program to match you with volunteer opportunities that support our communities
  • Support for life events such as birth, adoption, marriage or other changes to your family
  • Ergonomics and injury prevention to promote safe work environments
  • Paid time off
  • Disability benefits
  • Tuition reimbursement to support your education as you tackle your career goals
 
 
April A. Estes
ProEnlist, LLC
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Please do NOT email the recruiter.  Applications are only accepted via the apply link.
C2C Not Available for This Position




 
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