Utilization Review Clinician (RN, PT, OT) - Oregon

Position Overview

• Location Type: Home-Based (Must reside in Oregon)
• Job Type: Full Time
• Salary: Not provided in the text

This is a home-based position requiring the candidate to live in the state of Oregon. The role involves reviewing medical records for medical necessity and providing skilled nursing care to patients. Key responsibilities include patient evaluations, admissions, informational visits, and ensuring timely post-discharge visits with completed assessments to minimize readmissions. The Utilization Review Clinician will also collaborate with physicians and providers for care coordination and apply clinical knowledge to ensure medically appropriate, quality, cost-effective care.

Requirements

• Education: Bachelor’s Degree or equivalent work experience.
• Experience: 4-6 years of clinical nursing or therapy experience.
• Licenses: RN, PT, or OT Compact License highly preferred.
• Preferred Qualifications:
  • Experience in utilization review, case management, and/or managed care.
  • Experience with MCG/Interqual or other criteria-based applications.
  • General understanding of managed care guidelines and their impact on services.
  • Graduate of an accredited school of nursing or therapy.

Responsibilities

• Prior Authorization Reviews: Conduct prior authorization reviews and/or continued stay reviews for post-acute care services.
• Service Approval: Approve services in compliance with health plan guidelines, contractual agreements, and medical necessity criteria.
• Collaboration: Collaborate with case managers, physicians, and medical directors to ensure appropriate levels of care and seamless care transitions.
• Team Participation: Participate in team meetings, educational activities, and interrater reliability testing.
• Compliance: Ensure compliance with federal, state, and accreditation standards.
• Payer Support: Support all payer programs and initiatives related to the post-acute space.
• Benefit Determinations: Make benefit determinations about appropriate levels of care using clinical guidelines.
• Care Coordination: Coordinate benefits and transitions between various areas of care.
• Resource Utilization: Utilize knowledge of resources available in the healthcare system to assist physicians and patients effectively.
• Other Duties: Perform other job duties as assigned.

Application Instructions

• Not provided in the text

Company Information

• Not provided in the text