Utilization Review Nurse Salary in Portland, ME

Legacy HealthRN Operating Room Service Coordinator, Open HeartEqual Opportunity Employer/Vet/DisabledUS-OR-PORTLANDJob ID: 24-37488Type: Regular Full-TimeEmanuel Medical Ctr campusOverviewThe Legacy nursing philosophy focuses on patients and their families. Our nurses embody this philosophy in everything they do, as advocates, communicators, problem-solvers and caregivers. Their expertise is sought after and respected by our health care team. In short, they are the face of wellness at Legacy. Does this sound like an environment in which you could thrive? If so, we invite you to consider this opportunity. Legacy Emanuel Medical Center in North Portland plays a vital role as a local and regional leader in serious clinical illness or injury. With around-the-clock expertise for critical health issues, including experts in trauma, heart care, burns, significant wounds, stroke, brain surgery and more, Legacy Emanuel is central to the health of our community and critical to the care of the Northwest. Emanuel Medical Center is a Level 1 Trauma Center, Regional Burn Center and serves the needs of both adult hospital population as well as Randall Children’s Hospital at Legacy Emanuel. Currently there are 19 ORs/procedure suites, performing an average of 50 cases/day for both Adult and Pediatric specialties including, cardiovascular, thoracic, neurosurgery, urology, orthopedic, ENT, Burns, OMFS, Plastics, Gynaecology and robotics. In July 2018, construction commenced on the new Emanuel West tower which includes brand new operating rooms, PACU, Central Sterile and other support areas.ResponsibilitiesThe RN Operating Room Service Specialty Coordinator, Open Heart is accountable for the direct coordination and oversight of clinical practice and patient outcomes for their assigned clinical specialty. Works in collaboration with Open Heart surgeons, residents, nursing, and support staff in all phases of perioperative care. Acts as an expert clinical resource within their surgical service for staff, surgeons, patients and their families. Actively initiates and/or participates in review of intraoperative care provided within their specialty to identify opportunities for improvement in outcomes, implementation of evidence-based best practice, and effective resource utilization (supply cost, staffing). Consistently demonstrates integrity in all interactions with vendors. Facilitates effective communication with all members of the healthcare team to achieve highest level of care and outcomes. Promotes team-building among peers, staff, and support departments--serving as a positive role model within the perioperative setting. Assists in implementation of and adherence to policies, procedures and standards of care. QualificationsEducation:Academic degree in nursing (BSN or MSN/MN) required. Experience:Two years of operating room clinical experience at proficient to expert level of practice required. Prior experience in specific specialty area of focus preferred. Knowledge/Skills:Expertise in the area of responsibility. Competence in application of the Nursing process. Ability to organize, prioritize and apply problem solving skills. Ability to negotiate, collaborate, delegate and effect desired changes. Ability to apply appropriate teaching and learning principles for staff development and patient/family education. Must possess strong communication and leadership skills, including ability to lead by example. Must meet requirements of RN Staff Nurse Job Description and performs duties in any clinical capacity as needed. Keyboard skills and ability to navigate electronic systems applicable to job functions.Excellent interpersonal skills to work with multi-disciplinary team of staff, physicians, and support departments throughout the organization. LEGACY’S VALUES IN ACTIONFollows guidelines set forth in Legacy’s Values in Action.Equal opportunity employer/vet/disabled.PI239031037

Legacy HealthCase Manager - Resource TeamEqual Opportunity Employer/Vet/DisabledUS-OR-PORTLANDJob ID: 24-37512Type: Regular Full-TimeMultiple Locations - Portland MetroOverview You embody the legacy mission of making life better for others. Through your expertise and compassion, you guide the care management team, ensuring the highest level of care for acute and chronic patients. Your vision creates an ideal atmosphere in which care team members thrive and patients receive the respect and attention they deserve.The primary function of this job is to be available and flexible to float to various sites throughout Legacy Health System and provide RN Case Management services. Coordinates and facilitates interdisciplinary provision of comprehensive, patient-centered, quality health care throughout the continuum for patients with acute and chronic health conditions. Fosters achievement of optimal health care outcomes within accepted standards of care. Serves as an expert resource to the healthcare team regarding the continuum of care, efficient use of resources, Best Practice protocols, team-based care, quality indicators and improvements, and regulatory requirements. Ensures a smooth transition of care between multiple health care environments with planned handoffs. Partners with patients and families in identifying health care issues and barriers to self-care in order to set priorities and engage in appropriate interventions. Demonstrates cultural agility and employs health literacy guidelines to provide education regarding self-management strategies. Utilizes rapid quality improvement cycles to continuously monitor, evaluate, measure, and report progress of interventions and outcomes. Paces the case to assure appropriate and fiscally sound care coordination across the continuum. This position requires you travel to various Legacy Health locations. Click here to learn more about Legacy Health ResponsibilitiesThis position requires extensive knowledge of disease management to include diagnostics, treatment and prognosis, community resources and healthcare reimbursement. Minimum 2 years clinical nursing experience required. Relevant experience in one or more of the following healthcare areas preferred: Coordination of community resourcesCare management of diverse patient populationsAmbulatory Care Knowledge of levels of care throughout the health care continuum to include inpatient, emergency care, rehab, home health, hospice, long term acute care, SNF, ICF, ALF with an overall understanding of utilization management and resource management.Working knowledge of Care Management models across the continuum. Knowledge of six core components of case management: Psychosocial aspectsHealthcare reimbursementRehabilitationHealthcare management and deliveryPrinciples of practice i.e. CMS guidelines, Interqual criteriaCase Management concepts Excellent organizational skills.Health literate oral and written communication skills for effective interaction with all members of the patient’s health care team.Knowledge of transitional planning to and from all venues.Ability to determine and access appropriate community resources. Ability to engage patient/family in discussion of health care goals and decisions with attention to cultural and health literacy implications.Ability to adhere to and implement regulations in an effective manner. Must serve as a resource to all team members regarding regulatory issues.Keyboard skills and ability to navigate electronic systems applicable to job functions.QualificationsKnowledge of six core components of case management:Psychosocial aspectsHealthcare reimbursementRehabilitationHealthcare management and deliveryPrinciples of practice i.e. CMS guidelines, Interqual criteriaCase Management concepts General accountabilities and essential functions:Facilitates daily multidisciplinary care coordination meetings to clarify patient plan of care. Communicates with patients and their families concerning the progress of patient recovery goals and ongoing care needs. Organizes and/or participates in patient care conferences.Coordinates care and expected outcomes between patients/families and healthcare team including nurses, social workers, physicians, therapists, and community agencies and resources.Develops and maintains a collaborative working relationship with all team members. Follows evidence-based best practice. Serves as the clinical resource manager for patients with complex care needs. Provides consultations for patients who do not follow or have multiple variances from a pre-established clinical path. Assesses patient care priorities with patient and staff as part of the health care team and participates in determining outcomes of interventions.Collaborates with patient, family, and other health care professionals in the establishment of goals and implementation of patient plan of care. May provide home visits when necessary.Facilitates referrals, multidisciplinary review and planning for specific patients.Maintains currency in case management practice and principles specific to venue.Ensures transition plan reflects national guidelines and/or approved protocols/pathways.Maintains knowledge of professional standards of practice through participation in continuing education, community and professional activities, and committee membership.Assists patient care team to identify and coordinate appropriate level of care across the health care continuum.Focuses on promoting early intervention for complex patients and communicating a coordinated plan of care to prevent unnecessary complications and negative patient outcomes.Communicates with UM RN(s) and with insurance and community case managers, when appropriate, to discuss benefits and obtain authorization for alternative level of care. Assists health care team to incorporate the educational needs of patients and/or families concerning alterations in health and the disease process into the plan of care.Assists with patient and family education as appropriate and necessary.Collaborates with Legacy leadership to identify educational needs of staff.Participates in and/or leads committees and task forces.Participates in identifying needs and developing programs which facilitate attainment of organizational goals.Represents applicable clinical areas in the review and development of hospital and overall system policies, procedures, protocols, guidelines, and standards.Participates in Continuous Quality Improvement (CQI) activities.Participates in data collection, analysis and reporting of defined indicators to facilitate comprehensive evaluation of program impact.LEGACY’S VALUES IN ACTION:Follows guidelines set forth in Legacy’s Values in Action.PI239072037

Behavioral Health Care Management ClinicianRemote within OR, WA, UT, or ID. Candidates outside of these states will not be consideredAre you a Licensed Behavioral Health Professional that is passionate about making a difference? In this position, you would provide clinical care management to best meet the member's specific healthcare needs and to promote quality and cost-effective outcomes. You would 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 essential activities of case management including assessment, planning, implementation, coordination, monitoring and evaluation. Assessment: collection of in-depth information about a member's situation and functioning to identify individual needs. Planning: identification of specific objectives, goals, and actions designed to meet the member's needs as identified in the assessment.Implementation: execution of the specific case management activities that will lead to accomplishing the goals set forth in the plan.Coordination: organization, securing, integrating and modifying resources. Monitoring: gathering sufficient information to determine the plan's effectiveness and the evaluation phase should determine the effectiveness of reaching the desired outcomes. 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.Consults with physician advisors to ensure clinically appropriate determinations.Serves as a resource to internal and external customers.Collaborates with other departments to resolve claims, quality of care, member or provider issues. Identifies problems or needed changes, recommends resolution, and participates in quality improvement efforts.Responds in writing or by phone 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 and customer service skills.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 aboveBehavioral Health Clinical Manager would have a Master's Degree in Behavioral Health Discipline and 3 years of case management, utilization management, disease management, or behavioral health case management experience or equivalent combination of education and experience. Required Licenses, Certifications, Registration, Etc.Must have 3 years direct behavioral Health clinical experience as an independently licensed Master's level Behavioral Health Clinician (no associate or interns) in one of the areas of Psychology, Counselling, Social Work, or Marriage and Family Therapy (LICSW, LCSW, LMHC, LPC and LMFT). Clinical License must be unrestricted and current in state of residence.#LI-RemoteThe expected hiring range for a Behavioral Health Care Management Clinician is $42.00 - $44.00 an hour depending on skills, experience, education, and training; relevant licensure / certifications; and performance history. The bonus target for this position is 10%. The current full salary range for this role is $33.80 - $55.00 an hour. Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:medical, dental, and vision coverage for employees and their eligible family membersannual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)paid time off varying by role and tenure in addition to 10 company holidaysup to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)one-time furniture and equipment allowance for employees working from homeup to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see our External Total Rewards page.We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.If you need accommodation for any part of the application process because of a medical condition or disability, please email [email protected]. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our Careers site.

Oregon Health & Science UniversityOregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or [email protected] DirectorUS-OR-PortlandJob ID: 2024-29195Type: Regular Full-Time# of Openings: 1Category: Nursing-LeadershipPortland, OR (Marquam Hill)OverviewOperational LeadershipDrive operational performance initiatives. Direct the analysis and create the understanding off key operational and financial outcomes including: ALOS, case mix, ambulatory utilization, cost per case, inpatient volumes etc., to recognize trends, evaluate status, and in concert with physicians make decisions and organize interventionsProvides leadership in the coordination of service line meetings, working with clinical leaders, medical directors and members to develop agendas.Partners with others to enhance healthcare and, ultimately patient care through interdisciplinary activities, such as education, consultation, management, technological development, or research opportunitiesApplies systems theory with an understanding that how parts of a system relate to the overall systemLeads and practices patient/family advocacy and promotes patient-centered decisions and outcomesMaintains visibility and open communication with the staff and department leadershipCommunicates plans and decisions to department staff and other stakeholdersEnsures the care environment supports the provision of safe quality care, and a work place that promotes shared decision-making, accountability, autonomy and engagementReflects on own method of decision-making and the role of beliefs, values and inferences to develop leadership and performance capacityPractices within shared-governance structures to distribute leadership and promote decision-making appropriate level within the governance structureCelebrates successes and accomplishmentsPerformance ImprovementDevelops the service line quality plan in collaboration with Quality Management department and organizational leadersOversees all regulatory activity associated with Hospital accreditation and program certificationsDrives clinical performance initiatives. Review, monitor, and analyze monthly and quarterly reports to recognize trends, evaluate status, and in concert with physician co-leaders, makes decisions and organize interventionsEvaluates the practice environment and designs and implements quality improvement strategies to ensure nursing sensitive outcomes meets or exceeds established goalsEvaluates the impact/benefits of system, organizational, nursing, and department initiativesSupports workflow processes that builds a culture of safetyUses current research findings and other evidence to expand clinical knowledge, enhance role performance, and increase knowledge of professional issuesService Line Direction & Strategic PlanningAchieves performance objectives and influences decision making and action through matrix relationshipsUnder the guidance of OHSU Health Heart and Vascular Service Line executive sponsors, and in collaboration with the Strategy department, Medical and Surgical Directors, partner to define strategic business focus, i.e. growth, maintenance or curtailment of activities as appropriate, using integrated information about customer(s), market(s) and competitors to recognize and recommend initiatives that align with OHSU Strategic PlanWork with Strategy department and OHSU Health System Partners on strategic vision and operational planning in relationship to cardiovascular programs across the health systemBuilds and manages relationships with outside organizations that are beneficial in executing service line business and strategy, including those that add value to OHSU’s reputation at the regional and national level.Collaborates with other OHSU affiliates and health systems on an as-needed basis to grow and support cardiovascular services within the state and regionallyPartners on the development of tactics to achieve goals and strategies. Direct the execution of tactics to meet or exceed performance objectives of Heart and Vascular Service LineRecognizes linkages to institutional initiatives and incorporate those implications when solving problems and making decisionsActively participate in physician recruitment and retention strategiesIdentify capital funding required to support strategic initiatives and work with peers to prioritize and approve submissionsCollaborate with outside partners as business and clinical opportunities may ariseFinancial ManagementEvaluates service line leaders’ achievement toward financial performance targetsDevelops innovative solutions and applies strategies to obtain appropriate resources for nursingPromotes activities that inform others about cost, risks, and benefits or care, or of the plan and solution.ProfessionalismPromotes translation of theory, scope & standards into practice to exercise autonomy and decision-making authority at the leadership levelAdvances practice excellence by communicating a clear and consistent message about the ownership of role and standards -based professional practiceMentors and supports others to access resources for their professional developmentEngages in informal and formal processes of giving and seeking feedback regarding role performance from individuals, professional colleagues, representatives, administrators, and othersResponsibilitiesMaster’s degree or higher in nursing or related fieldMinimum 10 years’ experience in nursing leadership.Professional certification in nursing leadership-e.g. Nurse Executive/AdministratorUnencumbered Oregon RN license BLS for healthcare provider Demonstrated ability to elicit high levels of performance from employees at all levels in the organization and stakeholders from a variety of external sourcesDemonstrated ability to plan, organize and execute moderately complex business plansDemonstrated financial analysis and fiscal management skillsEffective communication, and the ability to successfully manage interpersonal relationships in high stress, fast paced environmentExperience that demonstrates the ability to successfully work in partnership with physiciansExperience that demonstrates the ability to meet stringent deadlines in a dynamic environmentMust have proven skills in project management and matrix managementDemonstrates skill in problem solvingExceptional interpersonal communication skills PI239214780

Pharmacy Services TechnicianLooking for candidates within Idaho, but the right candidate will be eligible for a remote role within our 4-state footprint (WA, ID, OR, and UT).Primary Job PurposeThe Pharmacy Services Technician is a corporate-wide technical support resource for pharmacy benefit, reimbursement, and other drug use issues which do not require clinical judgment. This function assists the Clinical Pharmacy Consultants and Pharmacy Services staff with formulary-related operations and other operational processes which require knowledge and experience with pharmaceuticals.Normally to be proficient in the competencies listed below:Pharmacy Services Technician would have a high school diploma or related certificate and five years of experience as a pharmacy services technician in a retail, hospital, or other licensed pharmacy setting or equivalent combination of education and experience. Pharm tech certificate may be substituted for two years of experience.Responsibilities:Performs all duties as described in this document unless doing so would require clinical judgement. In any situation in which clinical judgment is necessary, the Pharmacy Services Technician will seek assistance from appropriate medical personnel. Appropriate medical personnel will be available for support during normal business hours.Responds to non-clinical pharmacy issues from providers, pharmacy services staff, case managers, preauthorization nurses, ENCC personnel, and government programs personnel and customer service. These pharmacy issues include formulary drug coverage, appeal and reconsideration claim status, and pricing for drug claims.Completes daily formulary operational processes, including tracking, processing, and obtaining appropriate documentation for pharmacy medical exception requests, prior authorization requests, reconsiderations, and appeals. Prepares reconsideration requests for Clinical Pharmacy Consultant review by obtaining and organizing appropriate documentation, including, but not limited to medical chart notes/reports and medication profiles. Communicates (orally and by written documentation) information and determinations to providers and members as necessary.Obtains and organizes drug utilization data, including patient specific and population-based data, in a manner which facilitates clinical review and decisions by Clinical Pharmacist Consultants. Organizing data includes but is not limited to sorting drugs into appropriate therapeutic and generic categories.Assists with auditing and investigations of medication-related claims, cases, and providers to identify misuse of medications, misuse of (Regence HMO Oregon) resources, substance abuse, and erroneous and fraudulent billing practices. Investigates and organizes workflow for claims referred to Pharmacy Services for review and allowable determination (misc. J codes, providers on review, reconsiderations).Supports wellness and disease state management programs for Pharmacy Service and corporately which contribute to NCQA accreditation and ongoing quality improvement.Contributes to and supports the corporation's quality initiatives through process improvement teams and by encouraging team and individual contributions toward the corporation's quality improvement efforts.Minimum Requirements:Knowledge of medical terminology, health care coding systems such as ICD-10, CPT and HCPCS and HIPAA regulations.Knowledge of pharmaceutical products, including orals, injectables, infusion products, and chemotherapy.Knowledge of general office practices and procedures.Demonstrated knowledge of grammar and techniques of business practice.Ability to interact effectively with a variety of health care professionals, including physicians, nurses, pharmacists, and billing staff both internally and externally.Demonstrate maturity, tact, diplomacy, and persuasiveness.Demonstrated ability to perform pharmaceutical pricing calculations.Ability to type 30 words per minute, 60 wpm preferred.Demonstrated ability to operate a variety of standard business machines including calculators, copiers, and faxes.Basic computer programs skills (Word, Excel, etc.).Ability to organize, plan, and prioritize daily workflow and projects within time constraints.Experience with health insurance and/or prescription benefits preferred.Work Environment:Work primarily performed in an in-home environment.May be required to work overtime.The base pay annual salary range for this job is $18.80 - $34.10/hour,depending on candidate's geographic location and experience.The annual incentive payment target for this position is 5%.Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:medical, dental, and vision coverage for employees and their eligible family membersannual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)paid time off varying by role and tenure in addition to 10 company holidaysup to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)one-time furniture and equipment allowance for employees working from homeup to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see our External Total Rewards page.We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.If you need accommodation for any part of the application process because of a medical condition or disability, please email [email protected]. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our Careers site.

Legacy HealthCase Manager SpecialistEqual Opportunity Employer/Vet/DisabledUS-OR-PORTLANDJob ID: 24-37678Type: On-Call (10% Differential and Min Shift Availability Required)Randall Children's Hospital at Legacy EmanuelOverview The Case Manager: Coordinates and facilitates interdisciplinary provision of comprehensive, patient-centered, quality health care throughout the continuum for patients with acute and chronic health conditions. Fosters achievement of optimal health care outcomes within accepted standards of care. Serves as an expert resource to the healthcare team regarding the continuum of care, efficient use of resources, Best Practice protocols, team-based care, quality indicators and improvements, and regulatory requirements. Ensures a smooth transition of care between multiple health care environments with planned handoffs. Partners with patients and families in identifying health care issues and barriers to self-care in order to set priorities and engage in appropriate interventions. Demonstrates cultural agility and employs health literacy guidelines to provide education regarding self-management strategies. Utilizes rapid quality improvement cycles to continuously monitor, evaluate, measure, and report progress of interventions and outcomes. Paces the case to assure appropriate and fiscally sound care coordination across the continuum.Randall Children’s Hospital at Legacy Emanuel is a regional center for the care of infants, children and teens. We offer unrivaled pediatric expertise in a state of- the-art facility designed exclusively for children. From routine care to the most complex cases, pediatricians and families trust us to provide the most advanced medical and surgical care for kids. ResponsibilitiesFacilitates daily multidisciplinary care coordination meetings to clarify patient plan of care. Communicates with patients and their families concerning the progress of patient recovery goals and ongoing care needs. Organizes and/or participates in patient care conferences.Coordinates care and expected outcomes between patients/families and healthcare team including nurses, social workers, physicians, therapists, and community agencies and resources.Develops and maintains a collaborative working relationship with all team members. Follows evidence-based best practice. Serves as the clinical resource manager for patients with complex care needs. Provides consultations for patients who do not follow or have multiple variances from a pre-established clinical path. Assesses patient care priorities with patient and staff as part of the health care team and participates in determining outcomes of interventions.Collaborates with patient, family, and other health care professionals in the establishment of goals and implementation of patient plan of care.Facilitates referrals, multidisciplinary review and planning for specific patients.Maintains currency in case management practice and principles specific to venue.Ensures transition plan reflects national guidelines and/or approved protocols/pathways.Maintains knowledge of professional standards of practice through participation in continuing education, community and professional activities, and committee membership.Assists patient care team to identify and coordinate appropriate level of care across the health care continuum.Focuses on promoting early intervention for complex patients and communicating a coordinated plan of care to prevent unnecessary complications and negative patient outcomes.Communicates with UM RN(s) and with insurance and community case managers, when appropriate, to discuss benefits and obtain authorization for alternative level of care. Assists health care team to incorporate the educational needs of patients and/or families concerning alterations in health and the disease process into the plan of care.Assists with patient and family education as appropriate and necessary.Collaborates with Legacy leadership to identify educational needs of staff.Participates in and/or leads committees and task forces.Participates in identifying needs and developing programs which facilitate attainment of organizational goals.Represents applicable clinical areas in the review and development of hospital and overall system policies, procedures, protocols, guidelines, and standards.Participates in Continuous Quality Improvement (CQI) activities.Participates in data collection, analysis and reporting of defined indicators to facilitate comprehensive evaluation of program impact. Collaborates with Legacy management team and staff in developing and utilizing quality indicators to monitor and evaluate care and outcomes.Participates as an active member in department meetings and group problem-solving sessions. Sponsors changes to improve department operations and supports others’ suggestions for change.In setting professional goals, includes attainment of case management certification. QualificationsEducation:Academic degree in nursing (BSN or higher) preferred. Experience:This position requires extensive knowledge of disease management to include diagnostics, treatment and prognosis, community resources and healthcare reimbursement. Minimum 2 years clinical nursing experience required. Relevant experience in one or more of the following healthcare areas preferred:Coordination of community resourcesCare management of diverse patient populationsAmbulatory Care Knowledge of levels of care throughout the health care continuum to include; inpatient, emergency care, rehab, home health, hospice, long term acute care, SNF, ICF, ALF with an overall understanding of utilization management and resource management.Working knowledge of Care Management models across the continuum. Knowledge/Skills:Knowledge of six core components of case management:Psychosocial aspectsHealthcare reimbursementRehabilitationHealthcare management and deliveryPrinciples of practice i.e. CMS guidelines, Interqual criteriaCase Management conceptsExcellent organizational skillsHealth literate oral and written communication skills for effective interaction with all members of the patient’s health care teamKnowledge of transitional planning to and from all venuesAbility to determine and access appropriate community resourcesAbility to engage patient/family in discussion of health care goals and decisions with attention to cultural and health literacy implicationsAbility to adhere to and implement regulations in an effective manner. Must serve as a resource to all team members regarding regulatory issues.Keyboard skills and ability to navigate electronic systems applicable to job functions. LEGACY’S VALUES IN ACTION:Follows guidelines set forth in Legacy’s Values in Action. PI239481008

Looking for a way to make an impact and help people?Join PacificSource and help our members access quality, affordable care!PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.Manage the daily operations, including oversight/supervision of the Care Management Team which may include the following: Health Services Representatives (HSR) Member Support Specialists (MSS) and Nurse Case Managers (NCM) and Behavioral Health Clinicians involved in care coordination and case management functions. Key participant in Health Services (HS) strategy, program development and implementation. Integrally involved in, and accountable for, the success of the PacificSource Care Management program development and performance internal measures as well as those established by regulatory entities.Essential Responsibilities:Work closely with the HS Director and other HS Managers to facilitate the development and implementation of new programs and processes to support ongoing success of department goals and initiatives, including but not limited to; ongoing activities related to physical and behavioral health integration and the development of a cohesive team approach to care management.Foster effective teamwork and performance. Manage change and encourage innovation. Build collaborative relationships, encourage involvement and initiative and develop goal orientation in others.Take a leadership role in initiation and implementation of departmental process/performance improvement activities Responsible for process improvement and working with other departments to improve interdepartmental processes. Utilize LEAN methodologies for continuous improvement. Utilize visual boards and frequent huddles to monitor key performance indicators and identify improvement opportunities.Serve as back-up for the Director of Care Management and Utilization Management Manager, as needed.Work collaboratively with the UM Director and Manager Team to develop, implement, and oversee the utilization management process to include; coordination of prior authorization needs for members engaged with care management, as well as the inpatient concurrent review process to ensure medical appropriateness, care coordination needs, and discharge planning for PacificSource patients who have been hospitalized.Develop and oversee the care management process to ensure care coordination and case management needs of PacificSource's are being met and their outcomes are being improved.Ensures consistent workflow and a comprehensive database of patients enrolled in care management and care coordination programs that allows for tracking of case loads, case management program success or failure, and patient and population outcomes.Ensure nurse case managers are providing timely notification of large cases to finance, underwriting, stop loss and other company leaders, as necessary.Serve as key driver and participant to ensure PacificSource care management programs are coordinated with the case management and care coordination functions of our provider and community partners.Responsible for oversight, management, development, implementation, and communication of HS case management and care coordination programs that coordinate and augment community partner programs.Oversee and monitor processes to ensure the protection of personal health information.Facilitate the provision of exceptional customer service to members, providers, employers, agents, and other external and internal customers. Ensure that the delivery of services meet acceptable standards and company and customer expectations.Monitor, evaluate, and report performance relating to volumes, quality, outcomes, accuracy, customer service, and other performance objectives.Serve as a liaison with all PacificSource departments to coordinate optimal provision of service and information.Serve as a resource and participate in development of policies, procedures, and operations.Collaborate and coordinate Health Services department staff between regional offices. At regional offices, represent Health Services by serving on management teams and support marketing and development initiatives towards achievement of PacificSource Health Plans goals specific to the region.Attend continuing education opportunities relevant to case management and care coordination to ensure that PacificSource care management programs maintain current best practices and implement innovative models of care.Maintain frequent and consistent department meetings and one-on-one meetings with individual contributors.Establish and monitor progress towards goals for care management programs, including case loads, outcomes, case timeliness, quality of interventions, training and physician outreach efforts.Encourage and support team members in their pursuit of case management and care coordination certifications.Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback to direct reports, including regular one-on-ones and performance evaluations.Develop annual department budgets. Monitor spending versus the planned budgeted throughout the year and take corrective action where needed.Coordinate business activities by maintaining collaborative partnerships with key departments.Actively participate as a key team member in Manager/Supervisor meetings and HS Management meetings.Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.Ensures ongoing monitoring and adherence to applicable state and federal regulatory and associated compliance requirements.Supporting Responsibilities:Meet department and company performance and attendance expectations.Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.Perform other duties as assigned.SUCCESS PROFILEWork Experience: 5 years clinical experience required. A minimum of 3 years direct health plan experience in case management, utilization management, or disease management, or equivalent preferred. Prior supervisory or management experience required.Education, Certificates, Licenses: Registered Nurse or Licensed Clinical Social Worker or other licensed healthcare or behavioral health care clinician, Oregon licensure required. Certified Case Manager Certification (CCM) as accredited by CCMC (The Commission for Case Management) strongly desired at time of hire. CCM certification required within two years of hire.Knowledge: Thorough knowledge and understanding of medical and behavioral health procedures, diagnoses, and treatment modalities, procedure codes, including ICD-9 & 10, DSM-IV & V, CPT codes, health insurance and State of Oregon mandated benefits. Knowledge of community services, providers, vendors and facilities available to assist members. Strong knowledge of health insurance; including managed care products as well as state mandated benefits. Ability to develop, review and evaluate utilization and care management reports. Experience in adult education preferred. Proficient in the use and implementation of the following tools and concepts across all teams within scope and accountability: Training, Coaching, Strategy Deployment, Daily Operations, Visual Management, Operational Improvement & Team Building/Development.Competencies:Building TrustBuilding a Successful TeamAligning Performance for SuccessBuilding PartnershipsCustomer FocusContinuous ImprovementDecision MakingFacilitating ChangeLeveraging DiversityDriving for ResultsEnvironment: Work inside in a general office setting with ergonomically configured equipment, as needed. Travel is required approximately 20% of the time.Skills:Accountable leadership, Collaboration, Communication, Data-driven & Analytical, Delegation, Listening (active), Situational Leadership, Strategic ThinkingOur ValuesWe live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:We are committed to doing the right thing.We are one team working toward a common goal.We are each responsible for customer service.We practice open communication at all levels of the company to foster individual, team and company growth.We actively participate in efforts to improve our many communities-internally and externally.We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.We encourage creativity, innovation, and the pursuit of excellence.Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

Care Management Nurse - Hybrid WA or OR - Vancouver ClinicPrimary Job PurposeThe Care Management Nurse provides 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. 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. General Functions and OutcomesResponsible for essential activities of case management including assessment, planning, implementation, coordination, monitoring and evaluation. Assessment: collection of in-depth information about a member's situation and functioning to identify individual needs. Planning: identification of specific objectives, goals, and actions designed to meet the member's needs as identified in the assessment.Implementation: execution of the specific case management activities that will lead to accomplishing the goals set forth in the plan.Coordination: organization, securing, integrating and modifying resources. Monitoring: gathering sufficient information to determine the plan's effectiveness and the evaluation phase should determine the effectiveness of reaching the desired outcomes. 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.Consults with physician advisors to ensure clinically appropriate determinations.Serves as a resource to internal and external customers.Collaborates with other departments to resolve claims, quality of care, member or provider issues. Identifies problems or needed changes, recommends resolution, and participates in quality improvement efforts.Responds in writing or by phone 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 RequirementsPalliative care experience preferredKnowledge 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 and customer service skills.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 Care Management Nurse 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 behavioral health case management experience or equivalent combination of education and experience. Required Licenses, Certifications, Registration, Etc.Must have licensure or certification, in a state or territory of the United States, in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline (e.g. medical vs. behavioral health) and at least 3 years (or full time equivalent) of direct clinical careMust have at least one of the following: Certification as a case manager from the URAC-approved list of certifications; or Bachelor's degree (or higher) in a health or human services-related field (psychiatric RN or Master's degree in Behavioral Health preferred for behavioral health care management); or Registered nurse (RN) license (must have a current unrestricted RN license for medical care management)Work EnvironmentDuties performed at home and in Vancouver ClinicThe expected hiring range for a Care Management Nurse is $36.00 - $48.60 an hour depending on skills, experience, education, and training; relevant licensure / certifications; and performance history. The bonus target for this position is 10%. The current full salary range for this role is $33.80 - $55.00 an hour. Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:medical, dental, and vision coverage for employees and their eligible family membersannual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)paid time off varying by role and tenure in addition to 10 company holidaysup to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)one-time furniture and equipment allowance for employees working from homeup to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see our External Total Rewards page.We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.If you need accommodation for any part of the application process because of a medical condition or disability, please email [email protected]. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our Careers site.

Legacy HealthDiabetes EducatorEqual Opportunity Employer/Vet/DisabledUS-OR-PORTLANDJob ID: 24-37778Type: Part Time - No BenefitsRandall Children's Hospital at Legacy EmanuelOverview As an expert in your field, you know that diabetes self-management varies from patient to patient. Some can manage their care on their own; others rely on assistance from caregivers. Each patient is unique, and so you treat all patients and family members with dignity and kindness as you offer individualized care education. In your work, you exemplify the Legacy mission of making life better for others. Randall Children’s Hospital at Legacy Emanuel is a regional center for the care of infants, children and teens. We offer unrivaled pediatric expertise in a state-of-the-art facility designed exclusively for children. From routine care to the most complex cases, pediatricians and families trust us to provide the most advanced medical and surgical care for kids.ResponsibilitiesEDUCATION: Theories and principles of family centered education are utilized to foster the educational development of patients and families.Provides patient and family instruction about the care of diabetes.Assists in the development of diabetes education materials and programs in collaboration with the health care team.May participate in outreach education in rural communities.Provides education on diabetes to members of the health care team.Communicates ongoing analysis of patient and family needs, verbally or in writing, to appropriate health care team members.Completes a minimum of 15 hours of continuing education per year in diabetes and education principles.Provides individual assessment, goal setting, planning, implementation of plan, and evaluation and follow-up.Utilizes evidence-based guidelines to guide practice. QUALITY OF SERVICE: Continuously evaluates and improves educational offerings to meet customer needs.Helps to develop and implement evaluation of educational offerings.Uses continuous quality improvement and LEAN principles to improve service to best meet customer needs. Measures outcomes.Participates in development of educational offerings.Assists in development of the program plan and participates in yearly program review.Informs patients of the existence and sources of appropriate diabetes supplies. RESEARCH: Collaborates with research personnel for patient and staff participation in clinical studies.Provides for dissemination of information regarding research developments and diabetes.Networks with other diabetes educators to stay current on modalities of education.Participates in research projects when appropriate. COST EFFECTIVENESS: Maintains productivity through activities that focus on resource utilization and preparation for managed care environment.Participates in the provision of cost effective patient education through the full continuum (inpatient, outpatient, home care).Assists in the development of system wide standards of care for diabetes education.Maintains education hours efficiently and productively according to budget plan. COLLABORATIVE COMMUNITY RELATIONS: Principles of communication and change theory are utilized to build community awareness of diabetes.Utilizes appropriate community resources to assist patients and families as needed.Participates in the planning and presentation of community and professional educational programs.Participates in the diabetes community through work in community programs.Participates in media relations and coverage for the center when the opportunity presents itself.QualificationsEducation: Registered Nurse; BSN preferred or Registered Dietitian. Completion of 30 hours of continuing education in diabetes education principles in prior two years. Experience: minimum two years of experience in diabetes education in acute care or ambulatory care setting. Skills/Knowledge: Basic familiarity with computers preferred. LEGACY’S VALUES IN ACTION:Follows guidelines set forth in Legacy’s Values in Action. PI239909086