Registered Nurse / RN - Utilization Management I

Role Overview

The Registered Nurse - Utilization Management I supports clinical operations by managing benefit reviews, appeals, grievances, and health-related services. This position focuses on Benefit Management, ensuring members receive medically appropriate care while managing medical expenses.

Estimated Hiring Range: $102,330.00 - $125,070.00 Bonus Target: 5% Annual SIP Target

Note: Current CareOregon employees must apply via the internal Workday site.

Essential Responsibilities

General Duties

• Communicate professionally with members and providers per State and Federal requirements.
• Maintain strict confidentiality of records and data.
• Refer members to care coordination as needed.
• Ensure accurate, complete documentation and manage service requests/authorizations.
• Collaborate with Medical Directors to determine medical necessity.
• Identify and refer quality of care issues for peer review.
• Issue denial notices based on established protocols.
• Support audits, regulatory activities, and system testing.
• Train new staff and cross-train in additional functional areas.

Functional Focus: Benefit Management

• Review pre-service requests and determine benefit coverage based on Medicare, Medicaid, and organizational guidelines.

Qualifications

Required Experience and Education

• Current, unrestricted Oregon RN license.
• Minimum 2 years of RN experience OR 1 year of RN experience plus 3 years in a healthcare role (e.g., billing, coding, medical assistant).

Preferred Qualifications

• More than 1 year of RN experience.
• Utilization management experience in Appeals/Grievance, Benefits Review, or Benefit Management.
• Experience with Medicaid and/or Medicare utilization management.

Knowledge, Skills, and Abilities

• Knowledge of Medicaid/Medicare benefits, DMAP rules, and medical coding (ICD-10, CPT, HCPCS).
• Strong critical thinking, problem-solving, and interpersonal skills.
• Proficiency in Microsoft Office and healthcare documentation systems.
• Ability to interpret complex policies and prioritize work independently.

Working Conditions

• Work Environment: Indoor/Office (Work from home).
• Member/Patient Facing: No.
• Travel: Occasional travel may be required.

Total Rewards Program

CareOregon offers a comprehensive benefits package, including:

• Medical, dental, vision, life, AD&D, and disability insurance.
• Retirement plan with employer contributions.
• PTO, Paid State Sick Time, and paid holidays.
• Wellness programs, FSA/HSA, and various supplemental benefits.

Equal Opportunity Employer

CareOregon is an equal opportunity employer. We select individuals based on job-related qualifications without regard to race, color, religion, sexual orientation, national origin, gender, gender identity, age, veteran status, or disability. Reasonable accommodations are available for qualified applicants.