2/28/2022

Job Description:

Bring your career to a community mental health provider while helping people live their best lives!  Do you enjoy exploring parks, wineries, trails, rafting, and more? Join our team!!

We are hiring IMMEDIATELY for a Registered Nurse Benefit Management Supervisor to join one of our community mental health providers!

Job Summary:

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 Benefits 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 the implementation of changes that support programmatic goals and objectives in alignment with the company’s mission and vision. This position also ensures staff is 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.

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 the 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 ongoing 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 staff and departments to identify opportunities to support financial impact initiatives.

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 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.

Knowledge, Skills, and Abilities Required

  • Knowledge of utilization management practice principles and industry-standard criteria
  • Knowledge of Interquel review criteria
  • Knowledge of Oregon Health Plan (OHP) benefits 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
  • Ability to work with the department, stakeholders, or customers to effectively resolve issues
  • Knowledge of ICD-9, CPT, HCPCS coding
  • 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 work in an environment with diverse individuals and groups
  • Ability to use basic word processing, spreadsheet, and database programs and the ability to learn more complex programs

Required:

  • Current unrestricted Oregon Registered Nurse’s license
  • Minimum 1-year utilization management or prior authorization RN experience
  • Minimum 1-year’ experience in a supervisory or lead position; lead roles should include regular assistance to a manager or supervisor in staff hiring, coaching, performance evaluation, and other supervisory tasks.

Preferred:

  • 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

“Careers and companies flourish when staff, clients, and candidates truly believe in the mission, know the role they play, and humbly reflect, evaluate, and act for the best interest of the communities served”