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REGENCE BLUECROSS BLUESHIELD OF UTAH Regence Utilization and Care Management in SALT LAKE CITY, Utah

Job Title: Regence Utilization and Care Management NurseRegence Utilization and Care Management Nurse Portland, OR; Salem, OR; Burlington, WA; Salt Lake City, UT; Lewiston, ID; Boise, ID; Tacoma, WA; Telecommute if residing within ID, UT, WA, or ORAre you a nurse that has a passion for making a difference? At Cambia, our values are fundamental to achieving our Cause of transforming the health care industry. They guide our actions and bring diverse perspectives together to improve the health care journey better for those we serve. All eight values are equally important and linked to the others: Empathy, Hope, Courage, Trust, Commitment, Collaboration, Innovation, and Accountability. These values are not just words on paper - we live them every day. In this position, you would provided utilization management (such as prospective concurrent and retrospective review) integrated with clinical care management (such as case management, disease management, and-or care coordination) to best meet the member's specific healthcare needs and to promote quality and cost-effective outcomes and appropriate payment for services. You would also oversees a collaborative process with the member and those involved in the member's car e to assess, plan, implement, coordinate, monitor and evaluate care as needed.Responsibilities* Responsible for both prospective (Sometimes called "precertification review" or "prior authorization",) and concurrent review (Utilization management conducted during a patient's hospital stay or course of treatment, sometimes called "continued stay review") prior to and during a patient's admission and treatment in a variety of healthcare settings.* Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care.* Utilizes evidence-based criteria that incorporates current and validated clinical research findings. Practices within the scope of their license.* Ability to initiate meaningful clinical dialogue with care providers-care recipients.* Consults with physician advisors to ensure clinically appropriate determinations.* Facilitates transitions of care through collaboration with the member, the facilities interdisciplinary team and Regence's Case Management programs to achieve optimal recovery for the member.* Responsible for essential activities of case management including assessment, planning, implementation, coordination, monitoring and evaluation.* Serves as a resource to internal and external customers.* Collaborates with other departments to resolve claims, quality of care, member or provider issues.* Works with other departments collaboratively for the purpose of providing holistic care interventions to ensure that a patient's needs are being met.* Responds in writing, by phone or in person to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues.Minimum Requirements:* Knowledge of health insurance industry trends, technology and contractual arrangements.* General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems.* Strong oral, written and interpersonal communication skills.* Patient focused approach to problem solving, such as looking for opportunities to help each member achieve optimal health outcomes.* Strong customer service skills including listening, patience, empathy, maintaining confidentiality and focus on meeting customer needs.* Ability to interpret policies and procedures, make decisions, and communicate complex topics effectively.* Strong organization and time management skills with the ability to manage workload independently.* Ability to think critically and make decision within individual role and responsibility.Normally to be proficient in the competencies listed above:* Utilization and Care Management Clinician would have a-an Associate or Bachelor's

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