Utilization Review Manager - Home Care jobs in Oregon

Full-time, Utilization Review Nurse (RN)

Must have active Oregon RN license

Primarily Telecommuting Position

Collaborative & Supportive Company Culture

Portland-Clackamas, OR – Business Location

*Qualified candidates must permanently reside either in OR, WA, NV, AZ.

Are you seeking a rewarding career opportunity where your professional talents will be recognized, utilized, and appreciated? If so, we encourage you to apply to our opening!

Innovative Care Management (ICM), a winner of Oregon's 2022 and 2023 TOP WORKPLACES, is seeking an experienced Utilization Review Nurse to join our growing and dynamic team and to provide telephonic utilization management in a primarily telecommuting organization. The right candidates will possess strong clinical, nursing, and critical thinking skills, as well as utilization management knowledge and expertise. The ability to work remotely and to openly communicate and collaborate with all levels of the organization are key requirements. A successful candidate will reside in Oregon, Washington, Nevada, or Arizona and will possess strong computer skills and general comfort navigating various digital platforms to ensure success during remote training with limited in person interactions with team members. Oregon RN license must be active. ICM has been providing telecommuting nursing opportunities for over 25 years and is committed to maintaining a strong telecommuting model even when the current public health crisis is resolved.

Who We Are – What We Embrace:

Innovative Care Management is an equal opportunity employer. As an organization, we fully embrace diversity and inclusion. We believe and uphold that equity, diversity, and inclusion are woven into every level of our business. As a team, we continue to build a company culture that respects, empowers, and encourages our employees, while at the same time elevating the diverse and unique contributions they make. We embrace and celebrate these contributions as they inspire innovation and our ability to connect, empathize, and care for our patients as well as the diverse communities we support and serve.

Position Overview:

Under the general direction of the Manager, Utilization Management Program, the Utilization Review Nurse has responsibility for assuring prompt, accurate handling of initial medical necessity reviews through the preauthorization and retrospective review process.

Specific Position Requirements and Responsibilities:
Review precertification requests for medical necessity, referring to the Appeals Specialist Nurse those that require additional expertise.

Listen to and accurately record Utilization Review updates from external sources in the iCare system.

Review clinical information for concurrent reviews, extending the length of stay for inpatients as appropriate.

Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:

• Promote improved quality of care and/or life
• Promote cost effective medical outcomes
• Prevent unnecessary hospitalizations
• Promote efficient lengths of hospital stays
• Prevent complications in patients under our care when possible
• Provide for continuity of care
• Ensure patients receive appropriate levels of care
• Provide appropriate consultation to precertification staff, Utilization Review Assistants, Utilization Management staff, and Case Management personnel.
• Provide support and maintain cooperative working relationships with all Innovative Care Management departments.
• Provide clinical advice and counsel to non-clinical precertification staff.
• Provide appropriate consultation and referral to Case Management, Disease Management and Healthy Mother Baby programs.
• Maintain accurate records of all communications and interventions related to patient related activities using appropriate software.

General Employee Requirements and Responsibilities:

· Establish effective rapport with all employees, company management, customers, clients, TPA partners, members, and physicians; actively maintaining ICM’s philosophy of non-adversarial patient advocacy.

· Actively support company and departmental QA/QI initiatives.

· Actively support departmental and corporate strategic plans and ensure successful implementation.

· Comply with all HIPAA compliance rules including Privacy, Security and Breach Notification.

· Follow all guidelines listed under the Code of Conduct in the Employee Handbook.

· Understand and comply with the Innovative Care Management Compliance program as outlined in the Employee Handbook.

· Demonstrate a clear understanding of the Mission, Purpose and Philosophy.

· Maintain confidentiality of all company and patient related information. Protect patient rights as defined in the patient Bill of Rights.

· Adhere to ethical business practices by striving to perform in a manner that conforms to the highest standards of ethical behavior, integrity, and honesty.

· Promote a safe and efficient working environment by adhering to agency policies and procedures.

· Treat employees, patients, and business partners with respect. Foster teamwork by trusting and supporting each other while encouraging collaboration at all levels of the organization.

· Honor diversity and supports cultural awareness through daily work and customer interaction.

· Promote health literacy by communicating in ways that are understandable to ICM clients. Be conscious of the use of plain language while avoiding the use of complex medical terms or jargon when interfacing directly with or writing content for consumers.

Work Experience, Qualifications, Additional Skill and Abilities, and Professional Competencies:

• 3 years of clinical knowledge and experience..
• 2 years of experience in utilization management, preferred.
• Ability to use a computer and quickly learn and master different software platforms as needed necessary to perform assigned tasks and responsibilities.
• Self-motivated with the ability to take initiative and work effectively in both an independent and collaborative business environment.
• Excellent relationship management skills, including a high degree of psychological sophistication and non-aggressive assertiveness.
• Demonstrated ability to problem solve multifaceted and/or emotionally charged situations.
• Ability to engage in abstract thought.
• Ability to successfully navigate conflict and reach mutually beneficial solutions.
• Strong organizational, task prioritization, and delegation skills.
• Previous training and demonstrated competence in medical necessity determinations, quality assurance and patient outcomes, preferred
• Previous experience in evidenced based criteria, preferred
• Strong focus on patient advocacy and empathy.

Education, Licensure, and Certification Requirements:

Nursing Degree (RN) from Accredited School of Nursing, required.

Proof of successful completion of educational requirements for a Registered Nurse (RN) as defined by the state in which the employee is to practice as well as proof of such licensure in good standing, required.

Must obtain sufficient continuing education to maintain active licensure in each state where continuing education units (CEUs) are required.

Ability to obtain other state licenses as required.

Work and Physical Conditions:

• Ability to use a computer keyboard and mouse 6-8 hours per day.
• Ability to dial, answer, and talk on a telephone with a headset for 6-8 hours per day.
• Ability to engage in sedentary activity by sitting or standing at a workstation for 6-8 hours.
• Ability to lift and transport office and computer equipment between office and home; less than 20 pounds.
• Work Remotely

Job Type: Full-time

Pay: From $40.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible schedule
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Referral program
• Travel reimbursement
• Tuition reimbursement
• Vision insurance

Schedule:

• Day shift
• Monday to Friday

Application Question(s):

• Only permanent residents of OR, WA, NV, or AZ will be considered. Please respond with your permanent state of residence.

Education:

• Associate (Required)

Experience:

• utilization management: 1 year (Preferred)
• clinical: 3 years (Required)

License/Certification:

• Oregon RN License (Required)

Location:

• Oregon (Required)

Work Location: Remote