RN Clinical Management Supervisor

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 Care Oregon’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:$ - $Bonus Target:

Bonus - SIP Target, 5% Annual Current Care Oregon 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 Care Oregon staff and departments to identify opportunities to support financial impact initiatives.

Work collaboratively with other Care Oregon departments.

Identify cases that require review by the Chief Medical Officer.

Ensure that Care Oregon 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…