Lead RN Care Coordinator Job Portland area,Oregon USA,Nursing

Let’s do great things, together!

About Moda

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together.

Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

Job Summary

Maintains Care Coordination caseload and directly oversees care coordination practices for all members involved in care coordination program. Monitors workflow and assists with training of RN staff. Ensures compliance with Healthcare Services as well as State mandated standards and maintains readiness for accreditation organization audits.
This is a FT hybrid position based in Portland, Oregon.

Pay Range

$78,911.43 - $98,639.28 Annually (depending on experience).

* Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Benefits

Medical, Dental, Vision, Pharmacy, Life, & Disability
401K
- Matching
FSA
Employee Assistance Program
PTO and Company Paid Holidays

Primary Functions

Investigates opportunities for health care alternatives and prepares cost effective plans to offer patients, families, and providers.

Identifies health services vendors to use in Care Coordination and coordinates with providers for member’s benefits as well as identifies and utilizes community resources that may be available to member.

Works closely with members, families, and providers, typically by telephone to outline a clear, proactive plan of care with patient goals and objectives and measurements to attain the same.

Effectively use the company’s internal systems to accurately determine eligibility, benefit plan, physician networks associated with the member’s plan. Documents accurate, readable, narrative notes related to cases and identifies and researches any problems and offers reasonable solutions.

Maintains an acceptable caseload within the guidelines outlined within the department’s policies and procedures and works assigned schedule to maintain phone coverage between the hours of 7am – 5:30pm, this includes closing cases in appropriate timeframe per department standards and maintain RN audit scores at or above the 90% benchmark.

Applies clinical expertise and judgment to ensure compliance with medical policy and criteria of for accepted standards of care while performing Utilization Review and Service Authorizations for members of assigned employer groups.

Consults with physician advisors to ensure clinically appropriate determinations.

Refers appropriate cases to Case Manager RNs for assessment.

Provides approvals and denials of requests in a professional and positive manner.

Reports on any case entered on the High Dollar Report in Rounds meetings.

Develops professional relationships with internal departments, including effectively communicating with support staff and customer service staff.

Contributes to the ongoing efforts of the department to foster a collaborative and team approach to case load.

Performs other duties as assigned.

Required Skills & Experience

Graduate of accredited 2-4 year program of nursing school.

Holds current unrestricted Oregon Registered Nurse license.

Must have 3 years recent hospital, home health, or acute care experience.

Type a minimum of 35 wpm on a computer keyboard and be proficient with Microsoft Office applications.

Strong analytical, problem solving, memory retention, organizational and detail-oriented skills.

Excellent communication skills with the ability to interact with all levels of staff, members and providers as needed.

Ability to be a self-starter and identify training needs of department.

Ability to defuse difficult/angry…