- Investigates opportunities for health care alternatives and prepares cost effective plans to offer patients, families, and providers.
- Identifies health services vendors to use in Care Coordination and coordinates with providers for member’s benefits as well as identifies and utilizes community resources that may be available to member.
- Works closely with members, families, and providers, typically by telephone to outline a clear, proactive plan of care with patient goals and objectives and measurements to attain the same.
- Effectively use the company’s internal systems to accurately determine eligibility, benefit plan, physician networks associated with the member’s plan. Documents accurate, readable, narrative notes related to cases and identifies and researches any problems and offers reasonable solutions.
- Maintains an acceptable caseload within the guidelines outlined within the department’s policies and procedures and works assigned schedule to maintain phone coverage between the hours of 7am – 5:30pm, this includes closing cases in appropriate timeframe per department standards and maintain RN audit scores at or above the 90% benchmark.
- Applies clinical expertise and judgment to ensure compliance with medical policy and criteria of for accepted standards of care while performing Utilization Review and Service Authorizations for members of assigned employer groups.
- Consults with physician advisors to ensure clinically appropriate determinations.
- Refers appropriate cases to Case Manager RNs for assessment.
- Provides approvals and denials of requests in a professional and positive manner.
- Reports on any case entered on the High Dollar Report in Rounds meetings.
- Develops professional relationships with internal departments, including effectively communicating with support staff and customer service staff.
- Contributes to the ongoing efforts of the department to foster a collaborative and team approach to case load.
- Performs other duties as assigned.
Full time contract
Job Types: Full-time, Contract
Pay: $40.00 per hour
Expected hours: 40 per week
Benefits:
- Life insurance
- Vision insurance
Schedule:
Experience:
- Managed care: 2 years (Required)
- Utilization management: 2 years (Required)
License/Certification:
- Oregon RN License (Required)
Work Location: Remote