Clinical Benefit Management Supervisor

Career Opportunities: Clinical Benefit Management Supervisor (18009) Requisition ID 18009 - Posted 09/28/2021 - CareOregon - Full Time - Permanent - Portland

To protect the health and well-being of our members, employees and community, CareOregon requires all employees to be fully vaccinated against COVID-19 or have an approved medical or religious exception as a qualification of employment.

Candidates who receive an offer of employment by CareOregon, must provide proof of COVID-19 vaccination or submit a medical or religious exception request, which will be evaluated in accordance with CareOregon's standard accommodation process.

Position Title: Clinical Benefit Management Supervisor

Department: Clinical Operations

Title of Manager: Clinical Operations Manager

Supervises: Benefit Review and Benefit Management Registered Nurses

Exemption Status: Exempt

Requisition: 18009

*This position is 100% remote within the state of Oregon or 6 SW Washington counties (Clark, Cowlitz, Pacific, Wahkiakum, Klickitat, Skamania)* Job Summary

This position supervises a remote a 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 CareOregon'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.

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 CareOregon staff and departments to identify opportunities to support financial impact initiatives.
  • Work collaboratively with other CareOregon departments.
  • Identify cases that require review by the Chief Medical Officer.
  • Ensure that CareOregon 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.
  • 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 CareOregon 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 provides 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.

Essential Organizational Functions
  • Perform work in alignment with the organization's mission, vision, and values.
  • Support the organization's commitment to equity, diversity, and inclusion by fostering a culture of open mindedness, cultural awareness, compassion, and respect for all individuals.
  • Strive to meet annual business goals in support the organization's strategic goals.
  • Adhere to the organization's policies, procedures, and other relevant compliance needs.
  • Perform other duties as needed.

Knowledge, Skills and Abilities Required

  • Knowledge of utilization management practice principles and industry standard criteria
  • Knowledge of Interqual review criteria
  • Knowledge of Oregon Health Plan (OHP) benefit 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


Lifting/Carrying up to 10 Pounds

Pushing/Pulling up to 0 Pounds

Pinching/Retrieving Small Objects

Crouching/Crawling

Reaching

Climbing Stairs

Repetitive Finger/Wrist/Elbow/

Shoulder/Neck Movement

0 hours/day

0 hours/day

0 hours/day

0 hours/day

0 hours/day

0 hours/day

More than 6 hours/day

Standing

Walking

Sitting

Bending

Seeing

Reading

Hearing

Speaking Clearly

0 hours/day

0 hours/day

0 hours/day

0 hours/day

More than 6 hours/day

More than 6 hours/day

More than 6 hours/day

More than 6 hours/day

Cognitive and Other Skills and Abilities

Ability to focus on and comprehend information, learn new skills and abilities, assess a situation and seek or determine appropriate resolution, accept managerial direction and feedback, and tolerate and manage stress.

Education and/or Experience

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

Working Conditions

  • Environment: This position's primary responsibilities typically take place in the following environment(s) (check all that apply on a regular basis):

Inside/office Clinics/health facilities Member homes

Other_________________________________________

  • Travel: This position may include occasional required or optional travel outside of the workplace, in which the employee's personal vehicle, local transit, or other means of transportation may be used.
  • Equipment: General office equipment
  • Hazards: n/a

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment

Veterans are strongly encouraged to apply.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.


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Category

Registered Nurses


Experience

1 year


Job type

Full time

Company
CareOregon
Posted
10/02/2021
Salary Range
$95,000.00 - 146,000.00
per Year
Salary range estimated by
Location
Happy Valley, OR 97086, US
Apply Now