Nurse I, II or III- Clinical Management

$75,160 - $95,824/Yr

Utah Retirement Systems - Salt Lake City, UT

Full-time - Entry Level

Remote - Salt Lake City, UT

Securities, Commodity Contracts, and Other Financial Investments and Related Activities

About the position

This entry-level nursing position at PEHP Health & Benefits involves working under the direct supervision of the Nursing Supervisor to coordinate healthcare needs for PEHP members. The role emphasizes the application of PEHP policies, effective communication with providers and members, and the ability to perform utilization reviews to ensure high-quality, cost-effective healthcare outcomes.

Responsibilities

• Identify and perform utilization review of selected cases.
• Identify needs based on clinical presentation, claims history, and discussions with members and providers.
• Minimize the use of out-of-network, out-of-state, or unnecessary services.
• Log authorized services/fees on the computer system.
• Ensure that information is current, accurate, and easily understood by claims adjusters and customer service.
• Verify medical diagnosis, status of current conditions, and specific needs/treatment plans by reviewing electronic medical records and past claims history.
• Facilitate smooth delivery of case management services.
• Assist adjusters in matching authorized services and negotiated fees with claims received.
• Interpret clinical information to assess implications for treatment and apply PEHP Clinical Policy and Master Policy.
• Effectively communicate decisions to members and providers.
• Assist Clinical Service Reps with questions and complex issues regarding medical necessity and appropriateness of services and preauthorization.
• Maintain strict confidentiality.
• Perform other related duties as required.

Requirements

• Currently licensed and in good standing as a Registered Nurse (RN) or Licensed Practical Nurse (LPN).
• For Nurse II: Minimum of three years of experience as an RN or nine years as an LPN in nursing, utilization review, or medical case management.
• For Nurse III: Minimum of three years of case management experience or five years of clinical experience; a bachelor's degree in nursing is preferred.
• Knowledge of HealthEdge HealthRules Payor and HealthRules Care Manager is preferred.

Nice-to-haves

• CMCN or CCM certificate preferred.
• Certified Professional Coder (CPC) is preferred.

Benefits

• Competitive salary with generous benefits.
• Personal development in a positive team environment.
• Excellent work-life balance.
• Remote work available for 9 out of every 10 workdays.