RN Clinical Benefit Management Supervisor

This is a fully remote position, open to applicants in Oregon.

📋 Description

• Supervise a remote team of Registered Nurses (RNs) working in Prior Authorization or Benefit Review.

• Manage referral processes, authorization requirements, reinsurance reporting, and inpatient review activities.

• Assist in the development of policies and procedures and lead the implementation of program modifications.

• Monitor the competency and productivity levels of staff.

• Fulfill RN duties during coverage needs or while reallocating work responsibilities.

• Identify opportunities for process enhancement and assess approved program modifications.

• Keep track of OHP, DMAP, and Medicare regulations, and communicate updates to relevant stakeholders.

• Attend state and other utilization and review meetings, providing reports to the Manager and department.

• Ensure that service requests and authorizations align with OHP, Medicare, and coverage determinations.

• Create unit and training materials.

• Complete utilization and review reports.

• Orient and train new hires, while providing continuous staff training.

• Suggest and implement technological improvements; maintain proficiency in QNXT and SharePoint.

• Prepare technology assessments for the Medical Director's review.

• Serve as a resource for department staff and Medical Directors.

• Support financial-impact initiatives and collaborate with other CareOregon departments.

• Identify cases that require review by the Chief Medical Officer.

• Assign reinsurance reviews based on the identification of high-cost cases.

• Supervise, coach, assess, and develop team members.

• Plan and oversee staffing, schedules, performance goals, and corrective actions in partnership with Human Resources.

⛳️ Requirements

• Current unrestricted Oregon Registered Nurse’s license.

• At least 1 year of experience in utilization management or prior authorization as an RN.

• Preferred: at least 1 year of experience in a supervisory or lead role, or completion of CareOregon’s Aspiring Leaders Program.

• Preferred: 2 years of experience in utilization management or prior authorization as an RN.

• Preferred: familiarity with Oregon Health Plan (OHP), DMAP, and/or CMS rules and regulations.

• Knowledge of utilization management principles and industry-standard criteria.

• Familiarity with InterQual review criteria.

• Understanding of OHP benefits, rules, and regulations.

• Knowledge of Medicare A and B benefits and Medicare Advantage regulations.

• Understanding of managed care and utilization management principles.

• Familiarity with ICD-9, CPT, and HCPCS coding.

• Ability to develop and implement processes and procedures effectively.

• Strong leadership and supervision capabilities.

• Proficient in using word-processing, spreadsheet, and database software.

• Excellent written and verbal communication skills.

• Ability to collaborate effectively with diverse individuals and groups.

• Capacity to perform necessary visual, auditory, communication, and repetitive hand/wrist movements for at least 6 hours daily.

🏝️ Benefits

• Bonus opportunity: SIP target of 5% annually.

• Comprehensive medical, dental, vision, life, AD&D, and disability insurance.

• Health savings account.

• Flexible spending account(s).

• Lifestyle spending account.

• Employee assistance program.

• Wellness program.

• Discounts available.

• Supplemental benefits including voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, and 529 College Savings.

• Retirement plan with employer contributions.

• Paid time off (PTO).

• Paid State Sick Time.

• Paid holidays.

• Volunteer time off.

• Jury duty leave.

• Bereavement leave.

• 401(k) contributions for employees not eligible for benefits.

• Option to work remotely from home.