Clinical Benefit Management Supervisor

Are you excited to step into a complex world that requires a blend of mind, heart and flexibility? We at CareOregon have been strengthening communities since 1994 by making health care work for everyone. As a nonprofit health plan largely focused on Oregon’s Medicaid population, we find fulfillment in supporting the underserved.

General Statement of Duties
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 Position Functions
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.

Management and Leadership

Train, supervise and evaluate performance of assigned staff.
Provide staff with the training, mentoring and resources necessary to carry out their work.
Ensure adherence to department and organizational standards, policies and procedures.
Ensure performance goals, expectations and standards are clearly understood by supervised staff.
Evaluate employees’ performance on an ongoing basis and take appropriate corrective action if needed.
Perform human resource functions in collaboration with Human Resources.
Maintain an understanding of the strategic vision of CareOregon, and the department’s contribution to the success of the plan.
Analyze staffing needs and provide recommendations to the Manager for decision making.

Essential Department and Organizational Functions
Propose and implement process improvements
Meet deadlines for completion of workload
Maintain agreed upon work schedule
Demonstrate cooperation and teamwork
Provide cross-training on specific job responsibilities
Meet identified business goals that contribute to departmental goals
Act as a good steward of the organization’s resources
Act as a role model to unit staff for professional behavior and appropriate work ethic
Perform other duties and projects as assigned

Knowledge, Skills and Abilities Required
Knowledge of utilization management practice principles and industry standard criteria
Knowledge of Interqual and Milliman/Robertson 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

Physical Skills and Abilities Required
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
Preferred:

2 years’ utilization management or prior authorization RN experience, including experience in a leadership or supervisory capacity
Experience with or detailed knowledge of the Oregon Health Plan (OHP) benefit and the Oregon Medical Assistance Programs (MAP) and 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.

Position Description »