Nurse I, II or III
Utah Retirement Systems - Salt Lake City, UT
posted 4 months ago
About the position
PEHP Health & Benefits is seeking a dedicated and compassionate nurse to join our team in an entry-level nursing position. This role is designed for nurses who can work efficiently under the direct supervision of the Nursing Supervisor, applying PEHP policies and principles effectively. The successful candidate will be responsible for identifying and coordinating the healthcare needs of PEHP members across various programs and departments, with a focus on delivering high-quality and cost-effective outcomes. The position requires strong judgment, integrity, and personal values that align with the company's standards. As a nurse at PEHP, you will engage in essential job functions that include performing utilization reviews of selected cases, identifying needs based on clinical presentations and claims history, and minimizing unnecessary services. You will log authorized services and fees into our computer system, ensuring that all information is current, accurate, and easily understood by claims adjusters and customer service representatives. Additionally, you will verify medical diagnoses and treatment plans by reviewing electronic medical records and past claims history, facilitating the smooth delivery of case management services. Effective communication is key in this role, as you will need to convey decisions to members and providers clearly. You will also assist Clinical Service Representatives with complex issues regarding medical necessity and appropriateness of services. Maintaining strict confidentiality is paramount, and you will be expected to perform other related duties as required. This position offers a unique opportunity to contribute to the health and well-being of Utah's public employees while working in a supportive and collaborative environment.
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 Representatives 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). New graduates may apply.
- Currently licensed and in good standing as a Licensed Practical Nurse (LPN) with a minimum of three (3) years of medical experience in direct patient care and utilization review; or an equivalent combination of education and experience.
- For Nurse II: Currently licensed and in good standing as a Registered Nurse (RN) with a minimum of three (3) years of experience, or as a Practical Nurse (LPN) with a minimum of nine (9) years of combined experience in nursing, utilization review, and/or medical case management. CMCN or CCM certificate preferred.
- For Nurse III: 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.
Nice-to-haves
- Knowledge of HealthEdge HealthRules Payor and HealthRules Care Manager.
Benefits
- Competitive salary with generous benefits
- Personal development in a positive team environment
- Excellent work-life balance
