Remote Utilization Review Rn Jobs in Portland, ME

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of"people caring for people," Martin's Point employees are on amission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Key Outcomes:

• Drives quality, timely claims processing to allow the health plan to achieve regulatory compliance, robust financial management and product strategy outcomes
• Oversee strong inventory management processes and enhance auto adjudication
• Delivers strong vendor oversight to optimize system processing to improve efficiency and accuracy; pursue new vendor opportunities including Request for Information (RFI)/Request for Proposal (RFP) as deemed appropriate
• Collaborates with business and IT teams to ensure system and operational readiness for system fixes, configuration, and project rollouts impacting claims processing
• Ensures operational readiness, testing, training, reporting, and communications are in place for claims processing updates
• Acts as business owner for claims processing and edit vendors, ensuring oversight of vendor, including day-to-day management, roadmap reviews and joint operating committee management
• Oversees, develops, and maintains documentation for claims and configuration processes and procedures with appropriate controls, reporting and quality assurance
• Develops work intake mechanisms, exploring and implementing tools to manage claims processing tickets, prioritize backlog and assess different work types (i.e., reporting, configuration, project vs. production fixes, etc.)
• Remains up to date on industry trends and advancements in claims provider reimbursement and system technology to identify opportunities for improvement
• Supports regular audits and quality checks to ensure data accuracy and system performance
• Oversees the research, development, implementation, ongoing operational maintenance and administration of provider payment methodologies and fee schedules for all provider types in support of provider contractual arrangements
• Supports the development and integration of provider payment policies and guidelines applicable to institutional and professional reimbursements and in concert with the Organization's products and member benefits
• Maintains all institutional and professional reimbursement methodologies leveraged by the organization. This includes demonstrating deep knowledge in industry standard payment methods
• Demonstrates working knowledge in the design and roll out of alternative payment methods that are focused on an incentive-based pay for value approach. This will require partnering cross organizationally to support the development of these new programs, and direct the operational activities necessary to stand them up
• Researches and provides recommendations on development of new or enhancements to existing reimbursements in conjunction with corporate and contractual initiatives including sound financial modeling/impact analyses

Education/Experience:

• Bachelor's degree required; Master's in business administration or comparable advanced degree strongly preferred
• CPC Preferred
• 10+ years health plan management experience required
• Experience managing vended system applications
• Experience with test plan development, strategy, and execution

Skills/Knowledge/Competencies (Behaviors):

• Demonstrates an understanding of and alignment with Martin's Point Values.
• Maintains knowledge and understanding of reimbursement agreements as well as claims and billing practices that impact cost and utilization data.
• Detailed knowledge of applicable regulatory and accrediting body standards (National Committee of Quality Assurance (NCQA), Centers of Medicare and Medicaid Services (CMS))
• Develops and maintains positive, effective working relationships with colleagues, vendors, and other internal and external customers.
• Excellent workflow and inventory management skills.
• Excellent problem solving, quantitative and analytical skills with the ability to assess performance against metrics.
• In-depth technical knowledge and ability to learn new technologies; knowledge of the Software Development Life Cycle (SDLC).
• Ability to manage, organize, and prioritize workload in a timely accurate manner.
• Ability to manage multiple competing demands and function independently.
• Knowledge of industry standards for claims and enrollment configuration, reporting and analysis.
• Knowledge of benefit coverage and servicing members, providers, and the DoD, CMS/ Medicare Advantage, and ME state insurance coverage.
• Knowledge of managed care computer systems, features, and reporting.
• Demonstrated interpersonal, communications, operational, team building, and quality improvement skills.
• Critical thinking: can identify root causes and implement short- and long-term sustainable solutions.

There are additional competencies linked to individual contributor, provider, and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org

Do you have a question about careers at Martin's Point Health Care? Contact us at:jobinquiries@martinspoint.org