Insurance Case Manager Jobs in Gresham, OR (NOW HIRING)

The Care Management department provides several major services to assure safe and efficient throughput of patients during their acute hospitalization and transition to the next level of care. Our goal is to balance individual clinical and psychosocial patient/family needs with the efficient and cost-effective utilization of resources while promoting quality outcomes.

RN case managers assess patients on admission for available family support, insurance resources, and potential discharge planning needs. They engage in daily multidisciplinary rounds Monday through Friday to develop and implement patient discharge plans with input from various other disciplines. The RN case manager is responsible for coordinating post-acute and discharge needs in a timely and cost-efficient manner. Using established criteria to determine appropriateness of continued hospital stay, RN case managers work with payors on obtaining needed authorizations for ongoing hospitalization and/or identified post-acute needs.

The RN Case Manager collaborates with the patient and family, members of the multidisciplinary team, community resources and agencies, and payors to ensure the patient's progress and level of care is appropriately determined. Intensity of service is dependent on individual patient needs as assessed by the case manager. RN case managers practice robust utilization and resource management.

RN case managers also frequently lead multidisciplinary and family care conferences involving complex care situations. They contribute to meeting OHSU's strategic plan of safe length of stay reduction and reduction in readmission rates.

Case Management is represented in every adult and pediatric unit and in the Emergency department. Each Case Manager has an office with a workstation near the unit they are assigned to. Communication factors: Case Managers are available by pagers, telephone/voicemail, Microsoft Teams, Epic Secure Chat, and e-mail.

Specialty Case Management Roles:

ED RN Case Manager: In addition to the above basic CM functions, also provides the following • Using approved criteria, conducts a comprehensive patient/family assessment and admission clinical review upon admission to the emergency department to ensure appropriateness of the care setting.• Provide early identification of high-risk patients and their needs.• Perform care coordination and discharge planning for patients in the Emergency department and Observation units.• Assess patients' potential to discharge from the emergency department with community care coordination.• Round with Advance Practice Providers at designated times BID.• Assist the transfer center with coordinating appropriate patient transfers out of the emergency department.• Educate providers regarding documentation requirements that support medical necessity determinations.• Deliver Medicare notifications including but limited to: Condition Code 44 notices, Observation notices, and Medicare Important Messages.• Document according to departmental policy.• Leads the effort to ensure compliance with CMS and other insurance regulations related to Care Management.• Other functions as assigned.

Evening Shift RN Case Manager • Provide nurse case management support to patients, families, and staff in both the inpatient and emergency department settings for the evening shift 7 days per week.• Receives referrals and hand offs from day shift case managers.• Complete hand off of information to day shift case managers.• Trouble shoot and resolve any discharge delays or barriers carrying over into evening shift.• Other functions as assigned.

RN Case Managers are responsible for being aware of and complying with regulatory requirements of DNV, Medicaid, Medicare, and Oregon Nurse Practice Act.

• Minimum three (3) years of clinical nursing experience in the last 7 years.
• Minimum one (1) year of Care coordination/transitions of care, charge nurse, home health, and/or hospital at home RN experience.
• BSN Graduates: Baccalaureate Degree in Nursing from a program accredited by Commission of Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN) or Commission for Nursing Education Accreditation (CNEA) 30 days before start date.
• ADN Graduates: Associate Degree in Nursing from an accredited program 30 days before the start date.
• Associate degree Nurses required to enroll in BSN program within 3 years of hire and complete within 5 years of hire
• Current, unencumbered Oregon State Registered Nurse License
• BLS from AHA required. New hires will be enrolled and required to complete during orientation
• Must be able to perform the essential functions of the position with or without accommodation

Case Management Certification (ACMA, RN-BC, CMSA); Hospital based case management experience.

Proficiency in managing difficult and sensitive family and provider care conferences including adjustment to new levels of function, end of life discussions, imbalance of available resources (social, spiritual, medical, financial).

Progressive leadership positions within a nursing unit, examples include Charge nurse, UBNPC Chair/Member, Shared Governance councils.

Minimum two (2) years of Inpatient Case/Care Management experience in the last 5 years.

Length of Orientation – Experienced Nurse

• External candidates: OHSU & Nursing New Employee Orientation (NEO) for about a week.
• Either Transition to Practice (TTP) Program Specialty Fellowship/Fellowship Learning Pathway or Orientation experience for 3 days-26 weeks depending on the care area. An employment service agreement may apply.

This position also comes with great benefits! Some highlights include:

• Comprehensive health care plans. Covered at 100% of the cost for full-time employees and 88% for dependents.
• $50K of term life insurance provided at no cost to the employee
• Two separate above market pension plans to choose from
• Vacation - 192 to 288 hours per year depending on length of service, prorated for part-time
• Holidays - up to 64 holiday hours per calendar year (employees accrue.0308 holiday hours for each hour paid – included in vacation accruals)
• Sick Leave - 96 hours per year, prorated for part-time
• Substantial public transportation discounts (Tri-met and C-Tran)
• Tuition Reimbursement
• Innovative Employee Assistance Program (EAP) including extensive wellness resources

2 positions available

We are Oregon's only public academic health center. In addition to caring for patients, we lead groundbreaking research. We also train the next generation of health care professionals. As Portland's largest employer, we give you opportunities to learn and advance in a system of hospitals and clinics across Oregon and Southwest Washington.

All are welcome. OHSU welcomes people of all ages, ethnicities, genders, national origins, religions and sexual orientations. We are striving to build an anti-racist, multicultural institution and encourage people with diverse backgrounds to apply.

To request reasonable accommodation, contact askhr@ohsu.edu