Reviews, assesses, and evaluates clinical information used to support Utilization Management (UM) decisions based on established clinical criteria and applies intermediate knowledge of coding and medical record research. Facilitates professional communication to ensure the authorization process is completed in a patient centered manner with adherence to quality and timeline standards. Applies knowledge of applicable Medicare (CMS), Medicaid (OHA), and other plan specific rules and regulations to the authorization process. Reviews cases that have a low to moderate level of service intensity.
DEPARTMENT DESCRIPTION
Samaritan Health Plans (SHP) operates a portfolio of health plan products under several different legal structures: InterCommunity Health Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan. As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together.
EXPERIENCE/EDUCATION/QUALIFICATIONS
Current unencumbered Oregon RN License required upon submission.
BSN preferred.
One (1) year clinical experience required.
Experience or training in the following required:
Health care delivery systems and/or managed care patients.
Computer applications including electronic documentation (e.g., MS Office, EPIC, Clinical Care Advanced).
Experience in the following preferred:
Utilization management.
Medicare and Medicaid rules and regulations and health plan benefit structure and policy.
Seniority level
Entry level
Employment type
Contract
Job function
Health Care Provider
Industries
Staffing and Recruiting
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