Location: Remote. This position has the possibility of being 100% Remote.  

Most of the positions at YCCO are hybrid, meaning they have the flexibility to work both remotely and/or in-person.

Department: Heath Plan Operations                          FLSA Status: Exempt

Reports To: Utilization Management Manager          Physical Strength: Light (L)

Learn more about Yamhill Community Care:  click here

Summary

The Utilization Management (UM) – RN will utilize key principles of utilization management, while conducting prospective, concurrent, and retrospective reviews for authorization, appropriateness of care determination, and benefit coverage. This position analyzes clinical information, contracts, mandates, medical policy, evidence-based published research, national accreditation, and regulatory requirements to determine appropriateness to authorize or recommend the denial of clinical services both medical and behavioral health including addiction services pertinent to all age populations. Identify care management needs and refer members to care management as appropriate. 

Essential Duties

1. Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, not limited but including OHP Line Finder and Prioritized List, and Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, and all Yamhill Community Care (YCCO) guidelines and departmental Standard Operating Procedures (SOPs) to manage their member assignments.
2. Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high-cost / high-dollar services to support decisions and recommendations made to the medical directors as needed for approvals or denials.
3. Coordinates non-par provider / facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts to assist with benefit determination. 
4.  Creates referrals and support care coordination and navigation for members and providers to alternative care settings when appropriate.

Job Duties

• Coordinates and facilitates correct identification of patient status.
• Promotes the quality and cost effectiveness of medical care by applying clinical critical thinking skills through the appropriate application of policies and guidelines to authorization requests.
• Performs clinical reviews of prior authorization and reconsideration requests for appropriate care and setting, following guidelines and policies, and approves services or forwards requests to the appropriate medical director with recommendations for other determinations.
• Completes medical necessity and level of care reviews for requested services using clinical judgment and refers to medical director those that require additional expertise.
• Provides accurate and complete documentation with rational that was used to approve requests.
• Identifies members that are high risk or have conditions that may need case or disease management.
• Collaborates with various staff within provider network and health services team to coordinate member care.
• Maintains authorization turn-around times as defined by policy, guidelines, and regulatory requirements.
• Enters and maintains pertinent clinical information in health management system.
• Participates in clinical performance improvement activities to achieve set goals.
• Uses data to drive decisions and plan / implement performance improvement strategies related to UM activities.
• Participates in development, implementation, teaching, evaluation, and revision of departmental standards related to UM.
• Demonstrates positive and professional written, verbal, and nonverbal communication skills.
• Substantiates activity by documentation entered in a clear, concise, organized, and timely manner.
• Utilizes negotiation skills, which effectively promote constructive solutions.
• Reflects concise clinical pertinence in documentation for assigned patient population.
• Responds to all inquiries in a professional manner using Department guidelines and policies.
• Documents UM, quality, and risk concerns and refer to appropriate departments as applicable for follow-up.
• Completes assignments and all reports per guidelines and requirements.
• Applies advanced critical thinking and conflict resolution skills to resolve member and provider issues.
• Provides clinical knowledge and acts as a clinical resource to non-clinical team staff.
• Participates in utilization management committees and works on special projects related to utilization management as needed.

Essential Department & Organizational Functions

• Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members.
• Participates in the preparation and submission of regulatory and contract-required deliverables.
• Works closely with other YCCO departments, including Health Plan Operations and Compliance to assist with audits; including the External Quality Review (EQR), as needed.
• Proposes and implements process improvements.
• Meets deadlines for completion of assigned responsibilities and projects.
• Maintains agreed upon work schedule with punctual, regular, and predictable attendance.
• Demonstrates cooperation and teamwork using a professional and respectful demeanor.
• Provides cross-training on specific job responsibilities.
• Meets identified goals that contribute to departmental goals.
• Works collaboratively in a team and matrixed (cross-department) environment with a spirit of cooperation.
• Respectfully takes direction from Supervisor.
• Other duties as assigned.

Knowledge, Skills, & Abilities

• Knowledge of Medicaid / Medicare compliance and regulatory standards.
• Knowledge of disease and impact across all age spectrums.
• Knowledge of approved status determination criteria and apply consistently according to inter-rater reliability techniques.
• Knowledge of and ability to apply clinical practice guidelines such as Oregon Medicaid Line Finder / Prioritized List requirements, InterQual Guidelines, and clinical policies to service authorization decisions.
• Excellent interpersonal communication, problem-solving, and conflict resolution skills.
• Computer skills in word processing, database management, and spreadsheet desirable.
• Knowledge in areas of: Medicare and Medicaid UM regulations, McKesson InterQual, and Denial Management.
• Excellent organizational skills including the ability to handle multiple priorities and demands simultaneously in a dynamic work environment while maintaining high attention to detail and accuracy.
• Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a Matrix or shared resources across departments work model.
• Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook.
• Ability to communicate both professionally and effectively in all forms of communication.
• Ability to work in an environment with diverse individuals and groups.
• Ability to remain flexible, positive, and adaptable.
• Ability to work across the YCCO region and to work remotely, as needed.

Supervisory Responsibilities

This position has no supervisory responsibility.

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to the safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform their essential duties.

Education & Experience

Required:

• Degree in Nursing.

     OR:

• Master’s degree in other Health Services, including Behavioral Health. 
• Two (2) years of experience in Acute Clinical Care or Medical Management setting, adult and children.

     OR:

• Any combination of education and experience that would qualify candidate for the position.

Preferred:

• Experienced in Physical and Behavioral Health direct service.
• Experience with Coordinated Care Organization (CCO) / Medicaid Managed Care. 
• 3+ years’ experience with Utilizations Review.

Certificates, Licenses and/or Registrations

Required:

• Valid, unrestricted RN license in the state of Oregon.

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this position. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this position. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential duties.

While performing the duties of this job, the employee is regularly required to talk or listen. The employee is frequently required to sit, stand, walk, use hands and fingers, handle or feel, and reach with hands and arms. The employee is occasionally required to climb or balance, stoop, kneel, crouch or crawl. The employee may occasionally need to lift and/or move up to 25 pounds.

This position operates in a professional office environment and requires frequent use of standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Specific vision abilities required by this job include close vision, color vision, distance vision, depth perception, and ability to adjust focus. The noise level in the work environment is usually moderate.

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.