Utilization Management RN job in Grants Pass

AllCare Health is seeking a Full-Time Utilization Management RN who thrives in a team environment and has the ability to provide exceptional service and skills.
AllCare Health is a southern Oregon-based health organization, led by local physicians since 1994. In a progressive model of care, we combine medical, dental, and behavioral health services to provide Medicare, and Medicaid insurance coverage to our members. We also provide support to our providers through AllCare Independent Physician Association and AllCare e-Health Services

The Utilization Management RN position is responsible for providing efficient and quality utilization management services utilizing clinical knowledge to support achieving optimal clinical and financial outcomes.

Qualifications:
 Current Oregon RN license, free of any restrictions or disciplinary action pending, and able to legally and independently practice without the supervision of another licensed professional.
 Preferred Bachelor's degree (B. A.) from four-year College or university in Nursing; or five years related clinical experience and/or training; or equivalent combination of education and experience.
 At least two years of experience with utilization management, managed care, or clinical care within a hospital or skilled nursing center.
 Knowledge of CPT codes, HEDIS, HIPAA, ICD9, ICD10 codes, Medicare guidelines, NCQA, Coordination of benefits where applicable (i.e. Worker’s Compensation, Auto Insurance, Short and Long Term Disability), appropriate referrals to Ethics Committee, Corporate Compliance, Fraud and Abuse or Legal Services is required. Knowledge of Billing and Claims processing preferred.

Essential Duties:

 Performs clinical review for cost containment and appropriate utilization of services independently, or in collaboration with UM RN team, Care Coordinator/Team Leader, Intensive Case Manager, and/or Medical Director.
 Performs simultaneous multiple tasks within the concurrent and pre-service review process, including knowledge of different systems, reviewing for multiple members, and the ability to interpret and apply different benefits to the appropriate review request.
 Processes preauthorization requests to ensure members are receiving appropriate care, according to their benefits.

AllCare offers a great working environment. Candidates offered a position must be able to successfully pass a drug test and background check. Skills testing may be required.
For consideration, please submit your resume, cover letter and a list of your professional references online at: www.allcarehealth.com/careers

Please note-this is located at our office in Grants Pass and remote work is not available.

AllCare Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.