Regence Utilization and Care Management Nurse Portland, OR; Salem, OR; Burlington, WA; Salt Lake City, UT; Lewiston, ID; Boise, ID; Tacoma, WA; Telecommute if residing within ID, UT, WA, or OR
Are you a nurse that has a passion for making a difference? At Cambia, our values are fundamental to achieving our Cause of transforming the health care industry. They guide our actions and bring diverse perspectives together to improve the health care journey better for those we serve. All eight values are equally important and linked to the others: Empathy, Hope, Courage, Trust, Commitment, Collaboration, Innovation, and Accountability. These values are not just words on paper - we live them every day. In this position, you would provided utilization management (such as prospective concurrent and retrospective review) integrated with clinical care management (such as case management, disease management, and/or care coordination) to best meet the member's specific healthcare needs and to promote quality and cost-effective outcomes and appropriate payment for services. You would also oversees a collaborative process with the member and those involved in the member's care to assess, plan, implement, coordinate, monitor and evaluate care as needed.
Responsible for both prospective (Sometimes called "precertification review" or "prior authorization",) and concurrent review (Utilization management conducted during a patient's hospital stay or course of treatment, sometimes called "continued stay review") prior to and during a patient's admission and treatment in a variety of healthcare settings.
Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care.
Utilizes evidence-based criteria that incorporates current and validated clinical research findings. Practices within the scope of their license.
Ability to initiate meaningful clinical dialogue with care providers/care recipients.
Consults with physician advisors to ensure clinically appropriate determinations.
Facilitates transitions of care through collaboration with the member, the facilities interdisciplinary team and Regence's Case Management programs to achieve optimal recovery for the member.
Responsible for essential activities of case management including assessment, planning, implementation, coordination, monitoring and evaluation.
Serves as a resource to internal and external customers.
Collaborates with other departments to resolve claims, quality of care, member or provider issues.
Works with other departments collaboratively for the purpose of providing holistic care interventions to ensure that a patient's needs are being met.
Responds in writing, by phone or in person to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues.
Knowledge of health insurance industry trends, technology and contractual arrangements.
General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems.
Strong oral, written and interpersonal communication skills.
Patient focused approach to problem solving, such as looking for opportunities to help each member achieve optimal health outcomes.
Strong customer service skills including listening, patience, empathy, maintaining confidentiality and focus on meeting customer needs.
Ability to interpret policies and procedures, make decisions, and communicate complex topics effectively.
Strong organization and time management skills with the ability to manage workload independently.
Ability to think critically and make decision within individual role and responsibility.
Normally to be proficient in the competencies listed above:
Utilization and Care Management Clinician would have a/an Associate or Bachelor's Degree in Nursing or related field and 3 years of case management, utilization management, disease management, or experience or equivalent combination of education and experience.
Required Licenses, Certifications, Registration, Etc.
Must have a current and unrestricted Registered Nurse license, in WA, OR, ID, or UT and at least 3 years (or full time equivalent) of direct clinical care
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions.
Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members more than 90 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you're seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers' engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check are required.