RN Clinical Benefit Management Supervisor
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Job Description
CareOregon RN supervisor leading remote utilization management and prior authorization teams. Overseeing clinical reviews, regulatory compliance, staffing, training, and program improvements.
Responsibilities:
- Supervise a remote team of RNs in Prior Authorization or Benefit Review
- Oversee referral management, authorization requirements, reinsurance reporting, and inpatient review processes
- Assist with policy and procedure creation and lead implementation of program changes
- Monitor staff competency and production levels
- Perform RN staff duties during coverage needs or work reassignment
- Identify process improvement opportunities and evaluate approved program changes
- Monitor OHP, DMAP, and Medicare rules and communicate changes to stakeholders
- Attend state and other utilization and review meetings and report to the Manager and department
- Ensure service requests and authorizations comply with OHP, Medicare, and coverage determinations
- Develop unit and training materials
- Complete utilization and review reports
- Orient and train new employees and provide ongoing staff training
- Recommend and implement technology improvements; maintain knowledge of QNXT and SharePoint
- Draft technology assessments for Medical Director review
- Act as a resource for department staff and Medical Directors
- Support financial-impact initiatives and collaborate across CareOregon departments
- Identify cases requiring Chief Medical Officer review
- Assign reinsurance reviews based on high-dollar case identification
- Supervise, coach, evaluate, and develop employees
- Plan and monitor staffing, schedules, goals, performance, and corrective action in collaboration with Human Resources
Requirements:
- Current unrestricted Oregon Registered Nurse’s license
- Minimum 1 year utilization management or prior authorization RN experience
- Preferred: minimum 1 year experience in a supervisory or lead position, or completion of CareOregon’s Aspiring Leaders Program
- Preferred: 2 years’ utilization management or prior authorization RN experience
- Preferred: experience with Oregon Health Plan (OHP), DMAP, and/or CMS rules and regulations
- Knowledge of utilization management practice principles and industry-standard criteria
- Knowledge of InterQual review criteria
- Knowledge of OHP benefits, rules, and regulations
- Knowledge of Medicare A and B benefits and Medicare Advantage regulations
- Knowledge of managed care and utilization management principles
- Knowledge of ICD-9, CPT, and HCPCS coding
- Ability to develop and implement processes and procedures
- Ability to provide leadership and supervision
- Ability to use word-processing, spreadsheet, and database programs
- Effective written and verbal communication skills
- Ability to work effectively with diverse individuals and groups
- Ability to perform required visual, auditory, communication, and repetitive hand/wrist movements for at least 6 hours per day
Benefits:
- Bonus opportunity: SIP target of 5% annually
- 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
- 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
- PTO
- Paid State Sick Time
- Paid holidays
- Volunteer time
- Jury duty leave
- Bereavement leave
- 401(k) contributions for non-benefits-eligible employees
- Remote work from home
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