REMOTE Utilization Review Nurse - Managed Care

Welcome and thank you for considering a career at Advanced Health!
We are searching for collaborative, innovative people committed to a shared community vision for health to join our team. If you value being part of a team that makes a difference, please consider joining our team!

We are committed to offering:

Competitive wages

Paid Time Off (PTO), Sick leave, Health and life insurance, Flexible Spending- and Health Savings Account options, Tuition reimbursement, 401(k) and Roth retirement with generous employer match, and Profit-sharing

Team-oriented atmosphere that values each of our employees as an individual and their work-life balance

Remote work options and Flexible scheduling

Every employee shares the responsibility for achieving the Quadruple Aim of health care reform: member engagement and satisfaction, improving quality of care, managing costs, and honoring diversity and equity . By focusing on the people and communities we serve, we strive to ensure the dignity, privacy and confidentiality of members, their families, co-workers, and others. All duties are performed in compliance with organization’s policies and procedure, contractual obligations, and within federal and state laws and guideline including HIPAA, OSHA, and Waste Fraud and Abuse regulations.

Advanced Health, LLC team members are employed through Advanced Health and/or DOCS Management Services.

Check out our open positions!
Location: Coos Bay, OR

Job Id: 296-DOCS.UR.07

# of Openings: 1

We are currently hiring a Part-time 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!

Classification: NON-EXEMPT | Status & Schedule: PART-TIME, 20-HRS/WEEK, GENERALLY MONDAY – FRIDAY, BUT MAY INCLUDE ADDITIONAL HOURS TO MEET THE NEEDS OF THE POSITION

Location: REMOTE, LOCAL TO OREGON STRONGLY PREFERRED

Work Location: OR, CA, AZ, TX, FL

Salary: $35.29 - $47.37/HOURLY

Department: MEDICAL SERVICES/UTILIZATION REVIEW | 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 PCPs 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

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 rationale 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-related 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 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 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, ACEs, CLAS Standards, and universal access

Knowledge and understanding of how the position’s responsibilities contribute to the department and company goals and mission

Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse

Awarene ss and understanding of equity, diversity, inclusion, and the equity lens

Excellent people skills and friendly demeanor

Critical thinking skills to identify strengths and weaknesses of alternative solutions

Attention to detail and organizational skills

Ability to handle stress and sensitive situations effectively while projecting a professional attitude

Ability to communicate professionally, both verbally and in writing

Ability to work with diverse populations and interact with people of differing personalities and backgrounds

Sensitive to economic considerations and human needs

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., and 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.

Our application process is online using the above applicant portal links. If you need assistance at any time, please contact hrsupport@advancedhealth.com

Equal Employment Opportunity (EEO) Statement
Advanced Health CCO and DOCS Management Services are EEO employers providing equal employment opportunity to all qualified employees and applicants without unlawful regard to race, color, religion, sex, gender or expression (including gender nonconformity), sexual orientation, national origin, age, disability status, genetic information, protected veteran status, military service, marital status, or any other status protected by applicable federal, state, or local laws.

Reasonable Accommodation Statement
Advanced Health CCO and DOCS Management Services are committed to the full inclusion of all qualified individuals. As part of this commitment, we will ensure that persons with disabilities are provided reasonable accommodations. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact the HR Department: hrsupport@advancedhealth.com | 541-269-7400 ext. 263.

Advanced Health is located in the beautiful section of the southern Oregon coast in Coos Bay. We have many indoor and outdoor recreational opportunities. For more information including visitor information, please visit the following sites:

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