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Nurse II or III - Clinical Management

Salt Lake City, UT

Details

Hiring Company

Utah Retirement Systems

Positions Available

Full Time

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Position Description

NURSE II

NON-EXEMPT POSITION

Minimum: $27.35/hr.  Maximum $34.86/hr.

 

 

ESSENTIAL DUTIES & RESPONSIBILITIES

  1. Reviews claims data to identify cases of excess or inappropriate utilization. Identifies needs based on clinical presentation, claims history, discussion with member and provider.
  2. Intervenes in identified cases in support of PEHP programs. Uses clinical knowledge, current benefits, and community resources to coordinate site of service, utilization of emergency room and primary care services, post discharge plans, mental health and other services with members and providers.  Minimizes the use of out of network benefits.
  3. Documents activities in PEHP systems. Maintains files to ensure that information is current, accurate and easily understood. 
  4. Reviews recommendations for alternative benefits with the appropriate supervisor for approval.
  5. Assists adjusters to match authorized services and negotiated fees with the claims received.
  6. Provides outcome and cost saving reporting.
  7. Serves as a resource for PEHP staff especially Member Services, Appeals and Policy Management, Clinical Improvement and Clinical Management staff members. Responds to inquiries and communicates PEHP policy.  
  8. Interprets clinical information to assess implications for treatment and applies PEHP policy. Effectively communicates the decision to members, providers and PEHP staff.
  9. Audits select claims to verify services were ordered, received and paid appropriately.
  10. Maintains strict confidentiality in compliance with all applicable federal and state law and internal policies.
  11. Performs other related duties as required.

 

NURSE III

EXEMPT POSITION

Minimum: $69463.43/yr.  Maximum $85,550.42/yr.

 

ESSENTIAL DUTIES & RESPONSIBILITIES

  1. Performs outreach to select patients. Identifies adherence, treatment, utilization or disease related related problems. Identifies case specific solutions to solve these problems with the intent of reducing disease associated morbidity.
  2. Interprets clinical information to assess implications for treatment. Communicates benefits, therapeutic alternatives and PEHP policy to selected members, providers and PEHP staff.
  3. Intervenes in identified cases in support of PEHP programs. Uses clinical knowledge, current benefits, and community resources to coordinate site of service, utilization of emergency room and primary care services, post discharge plans, mental health and other services with members and providers. Minimizes the use of out of network benefits.
  4. Develops goals, reports progress and meets deadlines.
  5. Utilizes internal and community resources to educate and assist identified members.
  6. Analyzes and evaluates claims and other data to identify trends. Recommends strategies to improve care, increase efficiency and reduce cost. Utilizes data to identify patients who are, or may require high utilization. Presents data and conclusions to appropriate management. Identifies and corrects data discrepancies.  
  7. Collaborates with other departments. Serves as a clinical resource for PEHP staff and answers questions about complex medical conditions, procedures, outcomes, coding and benefits.
  8. Documents activities and conversations. Tracks and reports cost and disease related outcomes.
  9. Identifies opportunities for improvement and recommends changes to existing structure and workflow to improve performance.
  10. Participates on committees as assigned.
  11. Maintains strict confidentiality in compliance with applicable federal and state law and PEHP policy.
  12. Performs other duties as required

NURSE II

Education and Experience

Currently licensed and in good standing  as a Registered Nurse (RN) and a minimum of three (3) years OR currently licensed and in good standing as a Practical Nurse (LPN) with a minimum of nine (9) years of combined experience in a broad spectrum of nursing, utilization review, and/or medical case management. 

CMCN or CCM certificate preferred. 

CPC preferred.

 

NURSE III

Education and Experience

Currently licensed (or license eligible) as a Registered Nurse in the State of Utah, in good standing, with at least three (3) years of case management experience or five (5) years of clinical experience; or an equivalent combination of education and experience

A bachelor’s degree in nursing and experience working in case management or for a healthcare payor are preferred.

Certification in Managed Care Nursing (CMCN) or Certified Case Manager (CCM) is preferred.

Certified Professional Coder (CPC) is preferred.


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