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.

For most jobs, remote work is available for 9 out of every 10 workdays.

POSITION SUMMARY

This is a key position for experienced nurses who play a vital role in advancing PEHP’s mission of delivering high-quality, cost-effective healthcare benefits by ensuring members receive appropriate care while minimizing unnecessary utilization, thereby protecting both member well-being and organizational sustainability. The role requires reviewing claims data, coordinating care with members and providers, documenting activities in PEHP systems, evaluating alternative benefits, supporting adjusters with claims accuracy, providing outcome and cost-saving reports, serving as a resource for staff, interpreting clinical information to apply PEHP policy, auditing claims, and maintaining strict confidentiality. To be successful, an individual must be able to apply clinical knowledge effectively to assess treatment implications, communicate clearly and professionally with members, providers, and staff, analyze claims data to identify utilization patterns and ensure accuracy, coordinate care and resources to reduce costs and improve outcomes, and maintain accuracy and confidentiality in all documentation and processes.

ESSENTIAL JOB FUNCTIONS AND DUTIES

1. Performs outreach to select patients. Identifies adherence, treatment, utilization or disease 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 and cost outliers. Recommends strategies to improve care, increase efficiency and reduce costs. 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. Collaborates in and with other departments. Serves as a clinical resource for PEHP staff and answers questions about complex medical conditions, procedures, outcomes, coding and benefits.
8. Reviews and recommends changes to department, clinical, or corporate policies when applicable. Applies clinical knowledge, existing practice standards, and professional judgement with each recommendation.
9. Applies available policies, benefits, and judgement to evaluate concurrent and retrospective requests for services and appeals.
10. Applies available policies and benefits to direct services received out of state and other outlier cases. Directs to preferred locations of service.
11. Documents activities and conversations. Tracks and reports cost and disease related outcomes.
12. Identifies opportunities for improvement and recommends changes to existing structure and workflow to improve performance. Provides feedback and guidance regarding clinical aspects of core administrative systems, interfaces, processes and workflows.
13. Participates on committees as assigned.
14. Maintains regular and reliable attendance.
15. Maintains strict confidentiality in compliance with applicable federal and state law and PEHP policy.
16. Performs other duties as required.

MINIMUM QUALIFICATIONS

Education and Experience

Currently licensed as a Registered Nurse (RN) in the State of Utah, in good standing, with at least three (3) years of combined experience in a broad spectrum of nursing, utilization review, and/or medical case management OR currently a Licensed Practical Nurse (LPN) in the state of Utah, in good standing, with at least five (5) years of combined experience in a broad spectrum of nursing, utilization review, and/or medical case management.

Equivalent health insurance experience, preferably with PEHP, may be considered in lieu of clinical background.

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/are 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.
• Internal proprietary system(s)/applications.
• 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 significant knowledge of:

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

Must possess excellent communication skills:

• Interpersonal communication skills, both verbally and in writing.
• Negotiation techniques.
• Ability to draft technical reports, documents, and agreements.

Must have the ability to:

• Understand department reports, utilization patterns, and cost.
• Interpret clinical information and assess implications for treatment plans.
• Manage and coordinate varied operational functions and activities.
• 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.