Clinical Program Manager-RN (Utilization Management)

Samaritan Health Plans (
SHP
) provides health insurance options to Samaritan employees, community employers, and Medicare and Medicaid members.
SHP
operates a portfolio of health plan products under several different legal structures: InterCommunityHealth Plans, Inc. (
IHN
) is designated as a regional Coordinated Care Organization (
CCO
) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group
PPO
and
EPO
plans;
SHP
is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan. As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together. This is a remote position in which we are able to employ in the following states: Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin
JOB SUMMARY
/
PURPOSE T
he Clinical Program Manager
RN
serves as the cornerstone of
SHP
’s regulatory infrastructure within the utilization management department. This role is responsible for the development, testing, and validation of complex report queries that support federal and state regulatory deliverables. It also oversees the creation and maintenance of policies, procedures, work instructions, and audit tools, while ensuring staff are adequately trained on these materials. The Clinical Program Manager leads all aspects of program development and execution, collaborates with internal teams and external partners, and serves as a subject matter expert across the organization. The position will also oversee and partner other health plan functions such non-emergency medical transport and delegation audits.
EXPERIENCE
/
EDUCATION
/
QUALIFICATIONS C
urrent unencumbered Oregon
RN L
icense required within 90 days of hire.
BSN
preferred. Master's degree in a related field preferred. One (1) year clinical nursing experience plus four (4) years health plan, case management and/or utilization management experience required. Experience or training in the following required: Health care delivery systems and/or managed care patients. Computer applications including electronic documentation (e.g.,
MS O
ffice,
EPIC
, Clinical Care Advanced). Experience in the following preferred: Team leadership. Case management. Medicare and Medicaid rules and regulations and health plan benefit structure and policy.
KNOWLEDGE
/
SKILLS
/
ABILITIES L
eadership - Inspires, motivates, and guides others toward accomplishing goals. Achieves desired results through effective people management. Conflict resolution - Influences others to build consensus and gain cooperation. Proactively resolves conflicts in a positive and constructive manner. Critical thinking – Identifies complex problems. Involves key parties, gathers pertinent data and considers various options in decision making process. Develops, evaluates and implements effective solutions. Communication and team building – Lead effectively with excellent verbal and written communication. Delegates and initiates/manage cross-functional teams and multi-disciplinary projects.
PHYSICAL DEMANDS R
arely (1 - 10% of the time) Occasionally (11 - 33% of the time) Frequently (34 - 66% of the time) Continually (67 – 100% of the time)
CLIMB
-
STAIRS LIFT
(Floor to Waist: 0"-36") 0 - 20 Lbs
LIFT
(Knee to chest: 24"-54") 0 – 20 Lbs
LIFT
(Waist to Eye: up to 54") 0 - 20 Lbs
CARRY
1-handed, 0 - 20 pounds
BEND FORWARD
at waist
KNEEL
(on knees)
STAND WALK
–
LEVEL SURFACE ROTATE TRUNK S
tanding
REACH
- Upward
PUSH
(0 - 20 pounds force)
PULL
(0 - 20 pounds force)
SIT CARRY
2-handed, 0 - 20 pounds
ROTATE TRUNK S
itting
REACH
- Forward
MANUAL DEXTERITY H
ands/wrists
FINGER DEXTERITY PINCH F
ingers
GRASP H
and/Fist