A division of Utah Retirement Systems, PEHP is a non-profit trust with the vital job of providing health benefits to Utah’s public employees and their families.
The Care Coordination Nurse works to identify, research, and perform high touch outreach to members who appear to have excessive utilization of the ER or Inpatient services. For members whose excess utilization appears medically necessary, Personalized Care Coordination (PCC) helps the member and their providers problem solve and better coordinate care. For members whose excess utilization appears to be not medically necessary, Mandatory Care Coordination (MCC) is implemented. If the member does not cooperate with MCC, benefits may be suspended.
ESSENTIAL DUTIES & RESPONSABILITIES
Education and Experience
Currently licensed (or license eligible) as a Registered Nurse (RN) 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.
Knowledge, Skills, and Abilities
Successful RN applicants must utilize clinical expertise and critical thinking skills to work with members, providers and PEHP staff. Requires considerable knowledge of medical case management procedures and processes; community resources; insurance benefits and coding. Strong problem solving and negotiating skills. Must possess good interpersonal communication skills, including motivational interviewing, both verbal and written. The ability to work independently and deal effectively with workload and time deadlines in a well organized manner while managing several projects at once. Requires sound judgment in decision making. PC/Computer operations and various program applications, specifically intermediate Word and Excel skills.
Incumbent performs in a typical office setting with appropriate climate controls. Tasks require a variety of physical activities which do not generally involve muscular strain, but do require activities related to walking, standing, stooping, sitting, reaching, talking, hearing and seeing. Common eye, hand, finger dexterity required to perform essential functions.