PEHP Health & Benefits is a division of the Utah Retirement Systems that proudly serves Utah’s public employees through high quality and competitively priced medical, dental, life, and long-term disability insurance plans on a self-funded basis. As a government entity, we embrace both a public mission and a commitment to creating customer value, excelling in the market, and improving healthcare. We offer a competitive salary with generous benefits, personal development in a positive team environment, and excellent work-life balance.

This job may be filled at either of the levels listed below.

Nurse I- Min: $26.52/hr.  Max: $33.14/hr.

Nurse II- Min: $31.74/hr.  Max: $40.47/hr.

Nurse III- Min: $72,970.92/yr.  Max: $93,033.28/yr.

POSITION SUMMARY

This is an entry level nursing position for nurses who can demonstrate the ability to work efficiently under the direct supervision of the Nursing Supervisor, correctly applying PEHP policies and principles, following through on assignments, and communicating professionally and effectively with providers and members. The Nurse must always demonstrate judgment, high integrity, and personal values consistent with the company’s standards. The position involves identifying and coordinating the healthcare needs of PEHP members within a variety of programs and departments with the goal of providing high-quality, cost-effective outcomes.  

ESSENTIAL JOB FUNCTIONS AND DUTIES

1. Identifies and performs utilization review of selected cases. Identifies needs based on clinical presentation, claims history, discussion with member and provider. Minimizes the use of out of network, out of state or unnecessary services.
2. Logs authorized services/fees on the computer system. Ensures that information is current, accurate and easily understood by claims adjusters and customer service.
3. Verifies medical diagnosis, status of current condition(s), and specific needs/treatment plan by reviewing the electronic medical record, past claims history to determine information that may affect the current treatment plan. Facilitates smooth delivery of case management services.
4. Assists adjusters, if necessary, to match authorized services and negotiated fees with the claims received.
5. Interprets clinical information to assess implications for treatment and applies PEHP Clinical Policy and Master Policy. Effectively communicates the decision to members and providers.
6. Assists Clinical Service Reps with questions and complex issues regarding medical necessity and appropriateness of services and preauthorization.
7. Maintains strict confidentiality.
8. Performs other related duties as required.

NURSE I

Education and Experience

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 a broad spectrum of direct patient care and utilization review; or an equivalent combination of education and experience. 

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.

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.

Knowledge of HealthEdge HealthRules Payor and HealthRules Care Manager is preferred.

Knowledge, Skills, and Abilities

This list contains knowledge, skills, and abilities that are typically associated with the job. It is not all-inclusive and may vary from position to position:

Required technical skills include the working knowledge and ability of:

• Microsoft Office Suite.
• Health Care Information Systems.

Required mathematical skills include working knowledge of:

• Calculating discounts, interest, and percentages.
• Calculating allowed amounts and member cost share.

Must possess working knowledge of:

• Medical case management and claims review procedures and processes.
• Insurance benefits and design.
• Health Care Coding.

Must possess excellent communication skills:

• Interpersonal communication skills, both verbally and in writing.

Must have the ability to:

• Understand department reports, utilization patterns, and cost.
• Interpret clinical information and assess implications for treatment plans.
• Analyze a variety of health care issues and make recommendations.
• Problem solve and use sound judgment in decision making.
• Maintain effective working relationships with professionals, department heads, co-workers, and the public.
• Follow written and verbal instructions.
• Prioritize work.
• Perform within deadlines.
• Work well in a team environment as well as independently.
• Multi-task by handling a variety of duties in a timely and efficient manner.
• Follow through with assignments.
• Deal effectively with stress caused by workload and time deadlines.

The incumbent must always demonstrate judgment, high integrity, and personal values consistent with the values of URS.

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.