RN Clinical Benefit Management Supervisor
This position supervises a remote team of RNs in the area of Prior Authorization or Benefit Review. The Prior Authorization Supervisor oversees referral management and appropriate implementation of regulatory and authorization requirements. The Benefit Review Supervisor oversees reinsurance reporting and inpatient review processes including transitions to other levels of care. This position assists with the creation of policies and procedures and leads implementation of changes that support programmatic goals and objectives in alignment with CareOregon's mission and vision. This position also ensures staff are performing at required competency and production levels. At times, this position may perform the tasks of RN staff during times of coverage needs or reassignment of work.
Estimated Hiring Range:$126,720.00 - $154,880.00
Bonus Target:Bonus - SIP Target, 5% Annual
Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.
Essential Responsibilities- Identify opportunities to improve the program's effectiveness and efficiency of work processes.
- Implement, monitor and evaluate approved program changes.
- Keep abreast of all OHP/ DMAP/Medicare rules and regulations and inform Manager, unit staff and other stakeholders of changes that impact unit decisions and practice.
- Attend state and other meetings which impact utilization and review activities and report back to Manager and department.
- Ensure that services requests and authorizations, including SNF/ urgent or emergent inpatient requests, are processed according to the Oregon Health Plan (OHP) rules and regulations, Medicare regulations, and National and Local Coverage Determinations.
- Keep abreast of requirements for transplants, out of area services, reinsurance requirements, and single case agreement processes.
- Develop written material for unit use and training materials.
- Complete reports required for utilization and review activity and submit in a timely manner.
- Provide orientation to new unit employees or provide oversight to staff who will provide the orientation.
- Provide on-going training to address programmatic and unit staff needs in all areas of utilization management functions.
- Make recommendations regarding the use of technologies that may enhance departmental performance and serve as a departmental resource for the implementation of any such technology.
- Keep current on system process and issues, including QNXT functions and SharePoint, including upgrades and upgrade testing.
- Draft new technology assessments for Medical Director review.
- Act as a resource for department staff and Medical Directors.
- Work with identified CareOregon staff and departments to identify opportunities to support financial impact initiatives.
- Work collaboratively with other CareOregon departments.
- Identify cases that require review by the Chief Medical Officer.
- Ensure that CareOregon authorization decisions are based on coverage rules.
- Remain current regarding processes and tasks performed by all assigned staff work with department staff to determine coverage during times of unplanned absences and when necessary, cover an assignment.
- Assign reinsurance reviews to staff based on high dollar case identification.
- Provide periodic coverage for staff assignments in order to stay current with work processes or as needed to support the department when absences require management assistance.
Employee Supervision
- Supervise team and recommend team direction and goals in alignment with the organizational mission, vision, and values.
- Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens.
- Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations.
- Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff.
- Train, supervise, motivate, and coach employees; provide support toward employee development.
- Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision making.
- Ensure team adheres to department and organizational standards, policies, and procedures.
- Evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action).
- Perform supervisory tasks in collaboration with Human Resources as needed.
Experience and/or EducationRequired
- Current unrestricted Oregon Registered Nurse's license
- Minimum 1 year utilization management or prior authorization RN experience
Preferred
- Minimum 1 year experience in a supervisory, lead position or completion of CareOregon's Aspiring Leaders Program; lead roles should include regular assistance to a manager or supervisor in staff hiring, coaching, performance evaluation, and other supervisory tasks
- 2 years' utilization management or prior authorization RN experience
- Experience with the Oregon Health Plan (OHP) benefit, OHP's Division of Medical Assistance Programs (DMAP) and/or the Centers for Medicare and Medicaid Services (CMS) rules and regulations
Knowledge, Skills and Abilities RequiredKnowledge
- Knowledge of utilization management practice principles and industry standard criteria
- Knowledge of Interqual review criteria
- Knowledge of Oregon Health Plan (OHP) benefit package including rules and regulations that pertain to health plan operations
- Knowledge of Medicare A and B benefits and regulations governing Medicare Advantage plans
- Knowledge of principles of managed care and utilization management
- Knowledge of ICD-9, CPT, HCPCS coding
Skills and Abilities
- Ability to work with the department, stakeholders, or customers to effectively resolve issues
- Ability to use critical thinking skills in problem solving
- Ability to manage multiple tasks and to remain flexible in a dynamic work environment
- Ability to function autonomously and to effectively set priorities
- Ability to present a positive and professional image
- Ability to develop and implement processes and procedures
- Ability to provide effective leadership and supervision to groups of people
- Ability to read, write and verbally communicate effectively
- Ability to use basic word processing, spreadsheet and database programs and the ability to learn more complex programs
- Ability to work effectively with diverse individuals and groups
- Ability to learn, focus, understand, and evaluate information and determine appropriate actions
- Ability to accept direction and feedback, as well as tolerate and manage stress
- Ability to see, read, hear, speak clearly, and perform repetitive finger and wrist movement for at least 6 hours/day
- Ability to for at least 3-6 hours/day
Working ConditionsWork Environment(s): ☒ Indoor/Office • Community • Facilities/Security • Outdoor Exposure
Member/Patient Facing: ☒ No • Telephonic • In Person
Hazards: May include, but not limited to, physical and ergonomic hazards.
Equipment: General office equipment
Travel: May include occasional required or optional travel outside of the workplace; the employee's personal vehicle, local transit or other means of transportation may be used.
Work Location: Work from home
We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.
