Registered Nurse (RN) - Utilization Review
Good Samaritan Regional Medical Center
Corvallis, OR

Utilization Review RN I

Samaritan Health Plans (SHP) provides health insurance options to Samaritan employees, community employers, and Medicare and Medicaid members. SHP operates a portfolio of health plan products under several different legal structures: InterCommunityHealth Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services# self-funded employee health benefit plan. # As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services# mission of Building Healthier Communities Together. This is a remote position in which we are able to employ in the following states:#Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin Candidates residing out of state will need to be able to work Pacific Time Zone hours.# # JOB SUMMARY/PURPOSE Reviews, assesses, and evaluates clinical information used to support Utilization Management (UM) decisions based on established clinical criteria and applies intermediate knowledge of coding and medical record research. Facilitates professional communication to ensure the authorization process is completed in a patient centered manner with adherence to quality and timeline standards. Applies knowledge of applicable Medicare (CMS), Medicaid (OHA), and other plan specific rules and regulations to the authorization process. Reviews cases that have a low to moderate level of service intensity. # EXPERIENCE/EDUCATION/QUALIFICATIONS Current unencumbered Oregon RN License required. BSN preferred. One (1) year clinical experience required. Experience or training in the following required: Health care delivery systems and/or managed care patients. Computer applications including electronic documentation (e.g., MS Office, EPIC, Clinical Care Advanced). Experience in the following preferred:# Utilization management. Medicare and Medicaid rules and regulations and health plan benefit structure and policy. # KNOWLEDGE/SKILLS/ABILITIES Communication - Effective written and verbal communication skills provided to members, providers and organization staff.# Able to tactfully discuss issues, and listen to and understand complex information/situations. Ability to apply motivational interview techniques when working with members.# Proactively resolve conflicts in positive and constructive manner.# Confidentiality - Knowledge of State and Federal (HIPAA) laws pertaining to confidentiality of protected health information. Ability to comply with laws and maintain confidentiality of patient information.# Critical Thinking - Identifies complex problems. Involves key parties, gathers pertinent data and considers various options in decision making process. Develops, evaluates and implements effective solutions in a member centric manner. Social Perceptiveness - Ability to work with a diverse population from pediatrics to geriatrics. Basic understanding of age-related differences in caring for and/or communicating with members and caregivers. Possess personal sensitivity to the needs and experiences of others and a non-judgmental attitude towards persons of differing standards, values, lifestyles, and ages. Knowledge of Medicare and Medicaid rules and regulations and health plan benefit structure and policy. Ability to appropriately apply evidence based clinical practice and criteria to authorization requests. # PHYSICAL DEMANDS Rarely (1 - 10% of the time) Occasionally (11 - 33% of the time) Frequently (34 - 66% of the time) Continually (67 # 100% of the time) CLIMB - STAIRS KNEEL (on knees) SQUAT Static (hold #30 sec) # LIFT (Floor to Waist: 0#-36#) 40 - 60 Lbs # # # SIT ROTATE TRUNK Sitting REACH - Upward CARRY 2-handed, 20 - 40 pounds LIFT (Floor to Waist: 0#-36#) 20 - 40 Lbs # # STAND WALK # LEVEL SURFACE LIFT (Floor to Waist: 0#-36#) 0 - 20 Lbs LIFT (Knee to chest: 24#-54#) 0 # 20 Lbs LIFT (Waist to Eye: up to 54#) 0 - 20 Lbs LIFT (Overhead: 54# and above) 0 - 20 Lbs CARRY 1-handed, 0 - 20 pounds CARRY 2-handed, 0 - 20 pounds BEND FORWARD at waist ROTATE TRUNK Standing REACH - Forward PUSH (0 - 20 pounds force) PULL (0 - 20 pounds force) MANUAL DEXTERITY Hands/wrists FINGER DEXTERITY PINCH Fingers GRASP Hand/Fist * Samaritan Health Plans (SHP) provides health insurance options to Samaritan employees, community employers, and Medicare and Medicaid members. SHP operates a portfolio of health plan products under several different legal structures: InterCommunityHealth Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services' self-funded employee health benefit plan. As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services' mission of Building Healthier Communities Together. This is a remote position in which we are able to employ in the following states: Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin Candidates residing out of state will need to be able to work Pacific Time Zone hours. * * JOB SUMMARY/PURPOSE * Reviews, assesses, and evaluates clinical information used to support Utilization Management (UM) decisions based on established clinical criteria and applies intermediate knowledge of coding and medical record research. Facilitates professional communication to ensure the authorization process is completed in a patient centered manner with adherence to quality and timeline standards. Applies knowledge of applicable Medicare (CMS), Medicaid (OHA), and other plan specific rules and regulations to the authorization process. Reviews cases that have a low to moderate level of service intensity. * * EXPERIENCE/EDUCATION/QUALIFICATIONS * Current unencumbered Oregon RN License required. BSN preferred. * One (1) year clinical experience required. * Experience or training in the following required: * Health care delivery systems and/or managed care patients. * Computer applications including electronic documentation (e.g., MS Office, EPIC, Clinical Care Advanced). * Experience in the following preferred: * Utilization management. * Medicare and Medicaid rules and regulations and health plan benefit structure and policy. * * KNOWLEDGE/SKILLS/ABILITIES * Communication - Effective written and verbal communication skills provided to members, providers and organization staff. Able to tactfully discuss issues, and listen to and understand complex information/situations. Ability to apply motivational interview techniques when working with members. Proactively resolve conflicts in positive and constructive manner. * Confidentiality - Knowledge of State and Federal (HIPAA) laws pertaining to confidentiality of protected health information. Ability to comply with laws and maintain confidentiality of patient information. * Critical Thinking - Identifies complex problems. Involves key parties, gathers pertinent data and considers various options in decision making process. Develops, evaluates and implements effective solutions in a member centric manner. * Social Perceptiveness - Ability to work with a diverse population from pediatrics to geriatrics. Basic understanding of age-related differences in caring for and/or communicating with members and caregivers. Possess personal sensitivity to the needs and experiences of others and a non-judgmental attitude towards persons of differing standards, values, lifestyles, and ages. * Knowledge of Medicare and Medicaid rules and regulations and health plan benefit structure and policy. Ability to appropriately apply evidence based clinical practice and criteria to authorization requests. * * PHYSICAL DEMANDS * Rarely (1 - 10% of the time) Occasionally (11 - 33% of the time) Frequently (34 - 66% of the time) Continually (67 - 100% of the time) CLIMB - STAIRS KNEEL (on knees) SQUAT Static (hold >30 sec) * LIFT (Floor to Waist: 0"-36") 40 - 60 Lbs * SIT ROTATE TRUNK Sitting REACH - Upward CARRY 2-handed, 20 - 40 pounds LIFT (Floor to Waist: 0"-36") 20 - 40 Lbs STAND WALK - LEVEL SURFACE LIFT (Floor to Waist: 0"-36") 0 - 20 Lbs LIFT (Knee to chest: 24"-54") 0 - 20 Lbs LIFT (Waist to Eye: up to 54") 0 - 20 Lbs LIFT (Overhead: 54" and above) 0 - 20 Lbs CARRY 1-handed, 0 - 20 pounds CARRY 2-handed, 0 - 20 pounds BEND FORWARD at waist ROTATE TRUNK Standing REACH - Forward PUSH (0 - 20 pounds force) PULL (0 - 20 pounds force) MANUAL DEXTERITY Hands/wrists FINGER DEXTERITY PINCH Fingers GRASP Hand/Fist