Remote Rn Utilization Review Nurse Jobs in Portland, OR

Let’s do great things, together!

 
About Moda
Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.
Position Summary

This is a hybrid position based in Portland.  Responsible for coordinating and performing all oversight activities to ensure compliance with NCQA, State and Federal requirements for the delegated UM functions. Audits the delegates’ structure, programs, operational design, and denial decisions. Ensures compliance and maintains readiness for accreditation organization audits. Conduct quarterly Delegation Oversight Committee meetings.  Document discussions regarding compliance and delegated functions in meeting minutes.

Pay Range
$71,990.85- $89,988.57 annually

**Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range
Please fill out an application on our company page, linked below, to be considered for this position.

https://j.brt.mv/jb.do?reqGK=27780850&refresh=true

Benefits:

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Requirements:

1. Requires current unrestricted Oregon Nursing license as a registered nurse with
2. Experience in healthcare management and knowledge of regulatory requirements
3. Have a strong understanding of NCQA
4. Type a minimum of 35 wpm on a computer keyboard.
5. Proficiency with personal computer programs such as Microsoft Word and Excel.
6. Analytical, problem solving, memory retention, organizational and detail oriented.
7. Excellent verbal and interpersonal communication skills including management of the angry customer.
8. Ability to work well under pressure.
9. Ability to come into work on time and daily.
10. Project a professional business image telephonically and in person.
    

Primary Functions:

Perform pre-delegation review in accordance with NCQA requirements including: 

1. Review of all relevant policies and procedure
2. Review of ability to perform delegated function in the appropriate time frames
3. Review of clinical policies and comparison with current Moda Health guidelines
4. Review of contract terms and knowledge of scope of delegated activities
5. Review of workflow to implement delegated activities
6. Pre-delegation audit of sample files
7. Organizes site visit, agenda, and preparation of audit tools for pre-delegation review
8. Report pre-delegation review findings to the Medical Quality Improvement Committee

Perform annual review of delegation including:

1. Annual review of program documents and structure
2. Review of reports associated with delegated functions
3. Perform audit of selected files
4. Review updates to clinical policies and compare with Moda Health guidelines
5. Submit corrective action plans for non-compliant issues and review progress
6. Organizes site visit, agenda, and audit tool for annual file review
7. Report outcomes to the Medical Quality Improvement Committee
8. Ability to take initiative and problem solve
9. Work independently and as part of an integrated team
10. Performs other duties as assigned

Contact with Others

Internally with own department, Medical and Dental Customer Service, Professional Relations, Marketing, Medical Claims, Actuarial (Underwriting), Information Systems and Human Resources. Externally with accreditation organization, providers, provider offices and hospitals, members, and groups.

Working Conditions
Office environment with extensive close PC and keyboard use, constant sitting, and frequent phone communication. Must be able to navigate multiple computer screens. A reliable, high-speed, hard-wired internet connection required to support remote or hybrid work. Must be comfortable being on camera for virtual training and meetings. Work in excess of standard workweek, including evenings and occasional weekends, to meet business need.
 

Together, we can be more. We can be better.
 
​​​​​​Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training. 
For more information regarding accommodations please direct your questions to Kristy Nehler & Danielle Baker via our humanresources@modahealth.com email.