BMPS RN

BMPS RN at AllCare Health with the Benefit Management & Pharmacy department in Grants Pass, Oregon

We Are Seeking Qualified Candidates to Join Our Team!

AllCare Health offers competitive wages, an excellent benefits package including affordable healthcare, 401k retirement, wellness programs, and flexible schedule options.

Job Duties

• Verifies member eligibility, benefits, and coverage requirements and applies to service determination reviews.
• Monitors workflow queues for service determinations to ensure processed within required government timeframe.
• Makes service determinations based on medical appropriateness, utilizing applicable criteria, and guidelines.
• Identify Stoploss cases and reports as designated per policy.
• Identifies members that would benefit from a referral to Care Coordination and initiate internal referrals.
• Researches and locates applicable federal and/or state criteria and/or health plan policies for service determinations.
• Identifies complex cases, prepares, and presents case file to Complex Care Team meetings.
• Utilizes resources in a cost-effective manner.
• Identifies workflow deficiencies and recommends solutions to improve.
• Communicates effectively with all company staff-.
• Oversees problems to their resolution within compliance timeframes and identifies ‘report up’ when necessary.
• Works efficiently both independently and in a team environment.
• Adheres to workflows to maximize workflow processes.
• Changes direction quickly and anticipates the requirements of the day.
• Participates in peer review audits to assist in identifying quality improvement initiatives and offers suggestions for improvement in the review process.
• Builds a collaborative relationship and maintain a courteous and professional manner at all times with providers and other health care staff at all times.
• Reports quality of care issues identified during the utilization management review process.
• Maintains punctual, regular, and predictable attendance.
• Respectfully takes direction from leadership.
• Meets all required training including those listed in Relias Learning Module System (LMS).
• Other duties as assigned.

On Call Responsibilities

This position requires on-call responsibilities. During on call shifts, this role is either waiting to be engaged or in an engaged state. Schedules are provided in varying formats to ensure qualified personnel is available during our business requirements, for each area of responsibility. Required on call times may change throughout the year depending on business needs.

Supervisory Responsibilities

This position does not have any supervisory responsibilities.

Job Requirements

May require the use of personal vehicle for local travel (subject to mileage reimbursement).

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

Being bilingual in another language, including American Sign Language (ASL), is an invaluable skill that enhances our ability to deliver culturally responsive care. We strongly encourage you to apply if you are bilingual.

All relevant experience can be listed in your resume to perform essential duties of the position including the following: lived, volunteer, professional, or a combination of experience and education.

Education

• One-year certificate from college or technical school in LPN (For LPN only)
• Associate's degree (AA) from a two-year college or technical school in nursing.

Experience

Two to four years related experience and/or training in utilization management, managed care, inpatient care or home care coordination.

Certificates, Licenses, and/or Registrations

• Valid Oregon Driver’s License and vehicle insurance If employee resides in Jackson or Josephine County
• Valid Oregon LPN, RN Licensure free of any restrictions or disciplinary action pending, and able to legally and independently practice without the supervision of another licensed professional.

Technical Skills

• Knowledge of CPT codes, HEDIS, HIPAA, ICD-10 codes, Medicare guidelines, NCQA, Coordination of benefits where applicable (i.e. Worker’s Compensation, Auto Insurance, Short- and Long-Term Disability), appropriate referrals to Corporate Compliance, Fraud and Abuse or Legal Services is required.
• Knowledge of billing and claims processing preferred.
• Familiarity with the Healthcare industry.
• Exceptional writing, editing, and proofreading skills.
• Excellent organization and time-management skills.
• Excellent computer skills, including the Microsoft Office Suite (Outlook, Word, PowerPoint, and Excel).
• Knowledge of and compliance with HIPAA regulations.
• Excellent at identifying and implementing improvement activities and ensuring excellence.
• Excellent at interpreting data and using it to solve problems and gain new insights.
• Excellent at locating information and synthesizing information from various sources.
• Knowledge of the ways implicit bias, personal identity, and power and privilege impact individuals, organizations and systems.

Interpersonal Skills

• Demonstrate accountability, inspiring trust and confidence from others.
• Self-resolve most conflicts or misunderstandings with minimal need for direct supervision.
• Work with high initiative, energy and effectiveness in a fast-past environment.
• Effectively and professionally communicate with team members.
• Collaborate within a multidisciplinary, diverse team to provide professional service.
• Prioritize and organize work according to competing timelines.
• Allocate your time so that you can complete tasks within established deadlines.
• Adapt to change, learn quickly, and work with ambiguity.
• Use creativity and resourcefulness to solve new problems.
• Cope and self-manage during stressful situations.
• Maintain an attentive and empathetic demeanor.
• Maintain a high degree of professionalism and confidentiality.
• Create a pleasant experience for all customers, such as being personable and attentive.
• Meet timelines for goals safely and with high level of quality.
• Make decisions independently in accordance with established policies and procedures.
• Take initiative and apply sound judgment in completing tasks and responsibilities.
• Examine and shift behaviors, as appropriate.
• Commit to being culturally aware.

Language Skills

Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

Mathematical Skills

Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.

Computer Skills

Job requires specialized computer skills. Must be adept at using various applications including database, spreadsheet, report writing, project management, graphics, word processing, presentation creation/editing, communicate by e-mail and use scheduling software.

Reasoning Ability

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to work with problems involving several concrete variables in standardized situations.

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this job. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

The employee must occasionally lift and/or move up to 10 pounds. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is occasionally required to stand; walk and reach with hands and arms. The noise level in the work environment is usually moderate.

• The employee must be able to work from a home office for all scheduled shifts.
• The employee must be able to travel locally, occasionally.

Company Overview

AllCare Health Website: https://www.allcarehealth.com.

AllCare Health is incorporated as an Oregon Benefit Corporation and has earned the coveted Certified B Corp® status since 2017. As such, AllCare Health considers its impact on community, society, and the environment in all business decisions. We have long recognized the value in social, economic, and environmental concerns of our employees, customers, and community members. (Learn more about B Corps at https://bcorporation.net/about-b-corps)

AllCare Health headquarters are located in Grants Pass in Southern Oregon on the Rogue River, surrounded by mountains, forests, small farms, and breathtaking views. This thriving and energetic community is ideal for families and outdoor enthusiasts, with a temperate Pacific Northwest climate. We enjoy easy access to outdoor sports and recreation, river rafting, fishing, hiking, biking, wineries, outdoor concerts, the world-famous Ashland Shakespeare Festival, the stunning Oregon coast, magnificent redwood forests, pristine beaches, and much more.

The AllCare Health family of businesses is guided by our corporate principles:

Purpose | Working together with our communities to improve the health and well-being of everyone.

Values | Trust, Innovation, Relationships, and Voice.

Vision | Thriving, Inclusive, and Equitable communities.

Brand Promise | Changing Healthcare to Work for You.

AllCare Health is dedicated to building a diverse and authentic workplace centered in belonging and serving our growing community. If you are excited about this open position but your experience does not align perfectly with every qualification in this post, we encourage you to apply anyway or reach out to our human resources department. You may just be the right candidate for this role or others.

If you need accommodations, help in the application process, or wish to receive this job announcement in an alternative format, please call 541-471-4106 and ask for Human Resources.

All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sexual orientation, gender identity, sex, age, protected veteran or disabled status, or genetic information.