Utilization Review Nurse Team Lead

Conduct prior authorization and HRS Flex reviews applying nursing judgment to supporttimely cost-effective and high-quality care.

Identifyand escalate complex cases to Medical Directors; obtain and evaluateadditionalclinical documentation as needed.

Collaborate with care coordinators discharge planners and interdisciplinary teams to support care integration and safe transitions across settings.

Participate in discharge planning for members transitioning across levels of care ensuring continuity and support for physical and behavioral health needs.

Ensure access toappropriate servicesin the least restrictive setting whilemaintainingquality and continuity of care.

Maintain knowledge of Oregon Health Plan (OHP) Medicare and applicable regulatory requirements; ensure compliance with organizational and regulatory standards.

Serve as a clinical liaison with internal departments to resolve eligibility coordination of benefits and related issues.

Support quality improvement efforts byparticipatingin auditsidentifyingtrends and recommending process enhancements.

Provide training mentorship and ongoing support to staff on clinical workflows andutilizationmanagement protocols.

Develop andmaintaindepartmental resources tools and training materials to supportaccurateand consistent determinations.

Partner with leadership to support policy and procedure development and serve as a clinical resource for complex cases.

Perform other duties as assigned.

Active unrestricted Registered Nurse (RN) license in the state of Oregon or a Nurse Licensure Compact state

Graduate of an accredited nursing program

Minimum of two (2) years ofutilizationreview experience within a managed care organization

Experience applying clinical judgment to assess medical necessity using evidence-based guidelines (e.g. InterQual)

Working knowledge of Oregon Health Plan (OHP)/CCO requirements and applicable regulatory standards (e.g. NCQA CMS)

Proficiencyin Microsoft Office and electronic health record (EHR) orutilizationmanagement systems

Strong written and verbal communication skills with the ability to collaborate across interdisciplinary teams

Ability to manage multiple priorities analyze complex cases andmaintainattention to detail

Adherence to all federal healthcare program requirements; no history of suspension exclusion or debarment from Medicare or Medicaid

Valid drivers license and current auto insurancerequiredif job duties includedtravel

Bachelors or mastersdegree in nursing (BSN or MSN)

Experience with quality improvement audits and reporting

Knowledge of contractual benefits and alternative coverage options

Experience working with diverse populations and applying equity in decision-making

Bilingualproficiency including the ability to communicate and translate in another language