Let’s do great things, together
Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together.
Moda Health is seeking a Case Manger RN to perform case management within the boundaries of accreditation organization standards to ensure appropriate care is delivered timely and within the appropriate setting for Moda members; interacts with the member, family and care providers to develop, coordinate and monitor the member’s treatment plan.
• 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 advisers to ensure clinically appropriate determinations.
• Serves as a resource to internal and external customers.
• Applies clinical expertise and judgment to ensure compliance with medical policy and criteria of for accepted standards of care while performing Utilization Review and Service Authorizations for members of all books of business.
• 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, accurate and timely documentation.
• Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals, and established timelines
• Other duties and responsibilities as assigned
- Work is performed in office setting at Moda Tower in Downtown Portland, Oregon
- Work week is Monday through Friday
- Work in excess of standard work week to meet business needs may occur
- Prolonged amount of sitting and working on PC with extensive keyboard and telephonic work daily
- Occasional travel for meeting outside of the office
- Ergonomic Assessment is provided for each employee upon hire and as needed ensuring work station is ergonomically correct and user-friendly
Are you ready to be a betterist?
If you’re ready to make a difference that matters, we want to hear from you. Because it’s time to discover what’s possible.
Together, we can be more. We can be better.
Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law.