Healthcare Utilization Reviewer

7 days ago


Salt Lake, Utah, United States Utah Retirement Systems Full time
About the Role

We are seeking a skilled Nurse Case Manager to join our team at Utah Retirement Systems. As a Nurse Case Manager, you will play a critical role in ensuring the health and well-being of our members by identifying and coordinating their healthcare needs.

Key Responsibilities
  • Identify and perform utilization review of selected cases to ensure that members receive high-quality, cost-effective care.
  • Collaborate with healthcare providers and members to develop and implement effective treatment plans.
  • Log authorized services and fees on our computer system to ensure accurate and up-to-date information.
  • Verify medical diagnoses and treatment plans by reviewing electronic medical records and past claims history.
  • Facilitate smooth delivery of case management services and assist adjusters as needed.
  • Interpret clinical information to assess implications for treatment plans and apply PEHP Clinical Policy and Master Policy.
  • Communicate effectively with members and providers to ensure that they understand the decision-making process.
  • Maintain strict confidentiality and perform other related duties as required.
Requirements
  • Currently licensed and in good standing as a Registered Nurse (RN) or 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.
  • Ability to work efficiently under the direct supervision of the Nursing Supervisor and apply PEHP policies and principles.
  • Excellent communication and interpersonal skills, both verbally and in writing.
  • Ability to understand department reports, utilization patterns, and cost, and interpret clinical information to assess implications for treatment plans.
  • Problem-solving and decision-making skills, with the ability to work well in a team environment and independently.
  • Ability to prioritize work, meet deadlines, and perform within a fast-paced environment.
Preferred Qualifications
  • Certification in Managed Care Nursing (CMCN) or Certified Case Manager (CCM).
  • Knowledge of HealthEdge HealthRules Payor and HealthRules Care Manager.
  • Experience working in case management or for a healthcare payor.
Work Environment

The incumbent will perform in a typical office setting with appropriate climate controls. Tasks require a variety of physical activities that do not generally involve muscular strain, but do require activities related to walking, standing, stooping, sitting, reaching, talking, hearing, and seeing.



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