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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; Burlington, WA; Tacoma, WA; Seattle, WA; Medford, OR; Salem, OR; Lewiston, ID; Boise, ID; Salt Lake City, UT; Telecommute from WA, OR, ID, or UT.Are you a Registered Nurse that is passionate about making a difference? In this position, you would provide 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 special healthcare needs and to promote quality and cost-effective outcomes and appropriate payment for services. Oversees a collaborative process with the member and those involved in the member's care 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'sadmission 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.* Provides consistent and accurate documentation.* Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals, and established timelines.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 Degree in Nursing or related field and 3 years of case management, utilization management, disease management, or experience or equivalent combination of education and experience.* Must have a current and unrestricted Registered Nurse (RN) license in WA, OR, UT, or ID

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