Insurance Utilization Review Jobs in Oregon (NOW HIRING)

The Care Integration Specialist, working as a member of the interdisciplinary team, provides assistance and support to the Case Management team. This position helps facilitate a safe discharge plan, providing patients with services and resources as appropriate. This position collaborates with the treatment team and the patient to create an appropriate plan based on the resources available. This position manages a resource

guide to be utilized for the discharge planning process and is the point person for external vendors, insurances and care team members. This position functions under the direct supervision and management of the Care Integration Manager. Activities are related to discharge plan coordination, insurance utilization to ensure hospitalizations are covered as well as external resources for discharge and general support of the department employees.

Care Coordination:

• Review daily EPIC patient list with care management/treatment team to proactively create a discharge plan for the patient or relay any progress.
• Prioritize patients' needs prior to discharge based on coverage, social needs, medical needs and so on.
• Own discharge plan and help determine available resources for patients throughout their stay and relays this information to the patient/treatment team.
• After the treatment team identifies potential medical discharge needs, this information is taken and used to create an appropriate discharge plan by discussing with the patient, utilizing the resource guide and connecting with external vendors of what is safest and possible.
• Facilitate initiation of other appropriate services such as meal cards, AFS checks, family housing, etc.
• Follow the patient's progress with the multidisciplinary team by way of rounds to identify key points within the patient's care to independently start the discharge coordination process. This information will be documented within epic via the case management module or a note.
• Acts as a liaison between all care team members, updating each of the progress of the discharge plan and any potential barriers. This information will also be documented in epic via the case management module or note.
• Connect with patients regarding preference, changes, confirmation of services arranged and any additional updates or questions.
• Calls, photocopies, faxes, or mails clinical and referral information based on the resource guide to set up post-acute services which can include:
  • Home Health and Hospice agencies
  • Infusion vendors
  • DME vendors
  • Transportation vendors
  • SNF, ICF, AFH, RCF, and Assisted Living facilities
  • Shelter operators g. Outside Case Managers 
  • Medicaid Caseworkers
  • Insurance companies 
• Types letter of medical necessity, if needed 
• Follow up with any services arranged such as referrals/ insurance companies to ensure resources are obtained.
• Document all services arranged, referrals and continuous updates in epic via the case management module or a note.
• Arrange or identify follow up appointments post discharge including new, PCP, specialties, lab, radiology, etc. to prevent hospital readmissions.
• Other duties related to discharge without a requirement of a license 

Utilization Management:

• Reviews Admitting/IVS comments in EPIC, approved length of stay, clinical review due date, and insurance company UR contact information in Payor Comm of EPIC to minimize miss communication when coordinating resources.
• Calls appropriate OHSU or outside personnel to locate missing authorization number, approved length of stay, clinical review due date, and insurance company UR contact information to ensure resources are covered for post-acute coordination.
• Collects and organizes data related to clinical condition and treatment plan for use in utilization review by communicating with insurance providers. If denied, collaborates with treatment team to create a new plan.
• Faxes clinical information to third party payers, when allowed by payer, in order to obtain authorization for continued stay and discharge resources. Notifies Case manager when phoned clinical information is required otherwise, resources are determined and coordinated based on coverage. 

Other Duties as Assigned

• Associate degree in a healthcare related field that may include such areas as nursing, community health education, psychology or sociology is required.

• Bachelor's degree in a health care related field that may include such areas as community health education, psychology or sociology is preferred.

• Minimum two (2) years of healthcare setting, such as hospital, clinic or health plan, experience is required.

• Prior experience in case management in a health care setting, such as hospital, clinic or health plan is preferred.

Job Related Knowledge, Skills and Abilities (Competencies):

• Prior experience in case management in a health care setting, such as hospital, clinic or health plan is preferred.
• Demonstrated excellent written and verbal communication skills.
• Experience working with patients and their families.
• Must be flexible, self-motivated, proficient at multitasking, accustomed to frequent interruptions, and comfortable with change.
• Must be knowledgeable in medical and insurance terminology and procedures, and patient discharge process.
• Familiarity with insurance UR and disability qualifications.
• Able to work independently with minimal oversight 
• Must have time management skills with competing priorities.
• Able to maintain a commitment to their coworkers Demands critical thinking Requires knowledge of Microsoft Office Excel, Word, PowerPoint, and Outlook. 

• Prior experience in case management in a health care setting, such as hospital, clinic or health plan is preferred.
• EPIC software Kronos timekeeping software Crystal Reports software

This position requires staff to be able to commute onsite a minimum of 60% of the time or more.

Staff may be sitting at their desk up to 70% of the time

Staff may be required to walk around the hospital up to 30% of the time

This position may be located on patient units and requires direct patient interaction in their room.

This position may be exposed to contact precautions

Requires prioritization.

Frequent interruptions in an environment of frequent change and fluctuations.

For inpatient units accepts accountability and responsibility.

Subject to computer work for several hours, as needed.

Able to utilize office equipment within work area.

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