Registered Nurse (Rn) - Appeals & Grievances

Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.

Position Title: Registered Nurse (RN) – Appeals and Grievances

Department: Clinical Operations

Title of Manager: Quality Assurance Manager

Supervises: Non-supervisory position

Exemption Status: Exempt

Requisition ID: 23622

Pay and Benefits: Estimated hiring range $87,140 - $105,435 / year, 5% bonus target, full benefits. To learn more about our benefits, please visit www.careoregon.org/about-us/careers/benefits

Posting Notes: This remote, full-time role can be worked as 4 10-hour shifts or 8 5-hour shifts. Candidates will have the flexibility in choosing the hours they work between Monday and Friday. Candidates may reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin as long as they are licensed in Oregon at least 2 weeks prior to their hire date.

General Statement of Duties

The Registered Nurse – Appeals and Grievances will work closely with the Quality Assurance Manager in the tracking, documentation, collection, file maintenance and clinical oversight of the appeals and grievance process. The Registered Nurse – Appeals and Grievances will be responsible to adhere to all State and Federal regulatory requirements as relevant to grievances and appeals. This position will coordinate and act as a resource for grievance coordinators and appeals coordinators during the routine processing of both components. This role will work closely to identify opportunities for process improvement and assist in the development of strategies that will likely result in improvement. An overarching goal is the triple aim as a driver for this position: Improved health outcomes/improved member experience and reduced costs. The Registered Nurse – Appeals and Grievances will spend approximately 90% percent of time working at a PC terminal with the remainder of the time spent in meetings. Depending on deadlines and travel, hours may extend beyond regular business hours. As an exempt position the working hours vary.

Essential Position Functions

Program Development and Evalutation

• Work with Grievance and Appeals Coordinator to ensure that service requests/authorizations/complaints are managed in accordance to the OHP/DMAP/Medicare rules on direction of the Quality Assurance Manager
• Ensure that authorization decisions (CareOregon) are based on coverage rules
• Support Appeals Coordinator in assembling all relevant evidence for DMAP hearings or Maximus review
• Maintain accurate and complete documentation for files related to grievances and appeals
• Work closely with the Quality Assurance Manager to ensure clinical issues are addressed in a timely and thorough manner
• Provide clinical expertise to other department members, in evaluation of program outcomes, providing input for program activities
• Communicate with members ( both verbally and written) and providers in order to manage grievances and appeals; and provide status updates, as needed
• Coordinate and facilitate risk reduction strategies for quality and patient safety issues when opportunities are identified

Program Implementation

• Collaborate with the IS Department in the development of a data tracking process as needed
• Work closely with CareOregon staff to develop and implement training as appropriate
• Take lead in the implementation and ongoing administration of health improvement programs and provide ongoing feedback to Quality Assurance team and others as appropriate
• Participate in collaborative improvement initiatives with other health plans and organizations as needed
• Identify education/ training programs for network providers, members, other health care workers and CareOregon staff in support of appeals and grievance process

Regulatory Compliance

• Maintain confidentiality of all discussions, records, and other data in connection with quality management activities according to professional standards
• Coordinate and participate in periodic audits, general quality management and improvement activities, and other regulatory and accreditation activities, this may include participation in the analysis and summary of data for written reports and public presentations

Essential Department and Organizational Functions

• Meet deadlines for completion of workload.
• Maintain agreed upon work schedule.
• Meet identified business goals that contribute to departmental goals.
• Provide cross-training on specific job responsibilities.
• Demonstrate cooperation and teamwork.
• Propose and implement process improvements.
• Perform other duties as needed.

Knowledge, skills and abilities required

• Knowledge of utilization management practice principles and industry standard criteria
• Ability to use critical thinking skills in problem solving
• Excellent customer service skills
• Ability to manage multiple tasks
• Knowledge of process improvement technique tools and the ability to utilize
• Knowledge of Oregon Health Plan benefit package including rules and regulations that pertain to health plan operations
• Ability to work in an environment with diverse individuals and groups
• Ability to work with clinics that serve the medically vulnerable
• High degree of initiative and motivation along with the ability to effectively collaborate and plan with coworkers and others
• Basic word processing skills
• Ability to set goals independently and prioritize work to balance competing deadlines in a professional manner
• Ability to maintain strict confidentiality of information
• Excellent written and verbal communication skills
• Knowledge of current health plan operations with an emphasis on appeals and grievance processes
• Competency in basic statistical and data analysis functions
• Knowledge of Medicare A and B benefits and regulations that relate to Medicare Advantage plans
• Competency with computer software programs, e.g. MS Outlook, Word, Excel, and PowerPoint

Physical Skills and Abilities Required

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

A minimum of five (5) years of experience in healthcare preferably in a comparable position dedicated to quality and/or health improvement is required. Primary care and/or specialty clinic practice experience is desirable. Valid unrestricted Oregon RN required. BSN/Certified Professional in Healthcare Quality (CPHQ) preferred; MPH preferred.

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.
• Hazards: n/a
• Equipment: General office equipment

#Li-Remote

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.