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Job Field: Environmental Jobs
Location: PORTLAND, WA
Salary: $-
Job Type: Full Time

JOB SUMMARY:

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               <td align="left"><font style="font-size: 100%;">***Registration in iMatchSkills required for referral to this position; go to www.imatchskills.com***    REQUIREMENTS:  * 18 years or older  * High School Diploma or GED  * Valid Driver License   * Registered Nurse License  * 1 year experience as a Registered Nurse  * 1 year experience with appeals and concurrent review  * Type 40 wpm  * Proficiency with word processing, Word and Outlook software  * Pass pre-employment background check    JOB DUTIES:  * Drive to healthcare facilities  * Review requests for referrals and Prior Authorizations to determine if needed information has been provided and request additional information as needed  * Process all Level 2 service requests according to the OHP benefit, established protocols, review criteria and sound clinical judgment  * Submit questionable service requests to Chief Medical Officer   * Issue denial notices based on established unit protocols   * Review medical information and make authorization decisions based on review criteria and sound clinical judgment  * Review facility stays with Chief Medical Officer during regularly scheduled unit rounds  * Review questionable stays requiring immediate action with Chief Medical Officer on a daily basis  * Work with facility discharge planner to assist in discharge planning needs for problematic discharges  * Negotiate fee schedule for unusual situations after consultation with Chief Medical Officer and as deemed appropriate, Unit Manager and/or Director of Provider Relations Department  * Obtain all information needed to process appeal request  * Gather, analyze and assemble the documents  * Process appeal request based on established unit protocols  * Document Utilization Management Appeal cases according to established guidelines  * Issue decision notices based on established unit protocols  * Forward to the Care Coordinator RN, or company's Behavioral Health staff, members who require follow-up according to established unit protocols  * Screen situations to determine if OMAP dis-enrollment criteria applies and request dis-enrollment according to the unit protocols   * Provide training to new employees on specific tasks related to their job responsibilities  * Perform other duties and projects as assigned                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                </font></td>
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KEY REQUIREMENTS:

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Registered Nurses (RNs) 12 Months