BM & PS RN

Benefit Management & Pharmacy Services RN at AllCare Health with the BM & PS team!

We Are Seeking Qualified Candidates to Join Our Team!

AllCare Health offers competitive wages, an excellent benefits package including affordable healthcare, 401k retirement, wellness programs, and telecommute, remote work, and flexible schedule options.

Summary

This position is responsible for providing efficient and quality utilization management services utilizing clinical knowledge to support achieving optimal clinical and financial outcomes by performing the following duties.

Essential Duties

• Performs clinical review for cost containment and appropriate utilization of services.
• Processes service determinations based on member benefits and clinical criteria.
• Conducts concurrent reviews and collaborates with discharge planners for appropriate and safe discharge.
• Utilizes resources in a cost effective manner
• Identifies members that would benefit from a referral to Care Coordination and initiate internal referrals.
• Monitors workflow queues for service determinations to ensure processed within required government timeframe.
• Researches and locates applicable federal and/or state criteria and/or health plan policies for service determinations.
• Identifies complex cases, prepares, and presents case file to Complex Care Team meetings.
• Identifies workflow deficiencies and recommends solutions to improve.

On Call Responsibilities

• This position does have intermittent on call responsibilities.

Education & Experience

• Bachelor's degree (BA) from a four-year college or university; or one to two years related experience and/or training, or equivalent combination of education and experience.
• At least two years of experience with utilization management, managed care, or home care coordination.
• Knowledge of CPT codes, HEDIS, HIPAA, ICD-10 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.

Certificates, Licenses and/or Registrations

• Current Oregon Registered Nursing License, free of any restrictions or disciplinary action pending, and able to legally and independently practice without the supervision of another licensed professional.

Physical Demands & Work Environment

The employee must occasionally lift and/or move up to 10 pounds. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is occasionally required to stand; walk and reach with hands and arms. The noise level in the work environment is usually moderate. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this job. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

• The employee is required to work onsite for all scheduled shifts
• The employee is required to work from a home office for scheduled shifts, as needed, if approved by hiring manager