Utah Retirement Systems

  • NURSE III (Clinical Improvement)

    Location UT-Salt Lake City
    Posted Date 4 weeks ago(4/23/2018 3:52 PM)
    Job ID
    Care Coordination Nurse for MCC
    USD $64,183.00/Yr.
    USD $81,834.00/Yr.
  • About The Company

    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.

    Position Summary

    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.


    Job Description


    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. RN 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.

    Required Experience

    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.


    Work Environment

    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.


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