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CareOregon Registered Nurse - Benefit Management in Portland, Oregon

To protect the health and well-being of our members, employees and community, CareOregon requires all employees to be fully vaccinated against COVID-19 or have an approved medical or religious exception as a qualification of employment.

Candidates who receive an offer of employment by CareOregon, must provide proof of COVID-19 vaccination or submit a medical or religious exception request, which will be evaluated in accordance with CareOregon’s standard accommodation process.

Position Title: Registered Nurse – Benefit Management

Department: Health Services Operations

Title of Manager: Clinical Benefit Management Supervisor

Supervises: Non-supervisory position

Exemption Status: Exempt

Requisition: 18486

General Statement of Duties

The Registered Nurse – Benefit Management is responsible for supporting the utilization management functions within the department. These functions include processing referral and authorization requests.

Essential Position Functions

  • Review referral and authorization requests to determine if needed information has been provided; request additional information as needed.

  • Process requests according to Medicare guidelines, the Oregon Health Plan, established policies, review criteria and sound clinical judgment.

  • Submit requests to a Medical Officer when appropriate along with recommendations.

  • Send requests to third-party reviewers, as directed by Medical Directors.

  • Issue denial notices based on established unit protocols and in compliance with regulatory guidelines.

  • Perform work following established departmental policies, procedures, and timelines .

  • Forward to the Case Management RN, or CareOregon Behavioral Health staff, members who require follow-up according to established unit protocols .

    Essential Department and Organizational Functions

  • Propose and implement process improvements.

  • Meet deadlines for completion of workload.

  • Maintain agreed upon work schedule.

  • Demonstrate cooperation and teamwork.

  • Provide cross-training on specific job responsibilities.

  • Meet identified business goals that contribute to departmental goals.

  • Perform other duties as needed.

    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 applicable DMAP rules and regulations

  • Knowledge of ICD-10, CPT and HCPCS codes

  • Ability to provide critical attention to detail for accuracy and timeliness of processing service requests

  • Ability to organize work and remain focused under stressful conditions

  • 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

    Physical Skills and Abilities Required

    Lifting/Carrying up to 10 Pounds

    Pushing/Pulling up to 0 Pounds

    Pinching/Retrieving Small Objects

    Crouching/Crawling

    Reaching

    Climbing Stairs

    Repetitive Finger/Wrist/Elbow/

    Shoulder/Neck Movement

    0 hours/day

    0 hours/day

    0 hours/day

    0 hours/day

    0 hours/day

    0 hours/day

    More than 6 hours/day

    Standing

    Walking

    Sitting

    Bending

    Seeing

    Reading

    Hearing

    Speaking Clearly

    0 hours/day

    0 hours/day

    0 hours/day

    0 hours/day

    More than 6 hours/day

    More than 6 hours/day

    More than 6 hours/day

    3-6 hours/day

    Cognitive and Other Skills and Abilities

    Ability to focus on and comprehend information, learn new skills and abilities, assess a situation and seek or determine appropriate resolution, accept managerial direction and feedback, and tolerate and manage stress.

    Education and/or Experience

    Current unrestricted Oregon RN license required. Minimum 1 year RN experience required. Preference may be given to qualified candidates who have utilization management (UM) experience administering the Oregon Health Plan (Medicaid) and/or the Centers for Medicare and Medicaid Services (Medicare) benefits.

    Working Conditions

  • Environment: This position’s primary responsibilities typically take place in the following environment(s) (check all that apply on a regular basis):

    ☒ Inside/office ☐ Clinics/health facilities ☐ Member homes

    ☐ Other_____________

  • Travel: This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.

  • Equipment: General office equipment

  • Hazards: n/a

    Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment

    Veterans are strongly encouraged to apply.

    Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

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