Registered Nurse - Utilization Management I

Registered Nurse - Utilization Management IThe Registered Nurse - Utilization Management I is responsible for supporting specific utilization management (UM) program functions within the Clinical Operations department. UM program functions include Benefit Management, Benefit Review, Appeals and Grievances and Health Related Services (HRS). Together they support the healthcare needs of members, determine the best medically appropriate services, and apply clinical-based criteria for decision-making while managing medical expenses. NOTE: This is a remote position with preference given to candidates in Oregon and SW Washington. This position is on the Appeals and Grievances team. Estimated Hiring Range: $102,330.00 - $125,070.00 Bonus Target: Bonus - SIP Target, 5% Annual Priority will be given to candidates residing in Oregon and Southwest Washington. Current CareOregon Employees: Please use the internal Workday site to submit an application for this job. Essential Responsibilities General Duties Communicate with members and/or providers in a professional manner and in accordance with State and Federal requirements as needed to complete requests. Maintain confidentiality of all discussions, records, and other data in connection with quality management activities according to professional standards. Refer members to care coordination per policies and procedures. Maintain accurate and complete documentation. Collaborate with Medical Directors to determine medical necessity and app