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Nurse Case Manager
2 months ago
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 diagnosis 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.
- 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.
- 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.
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.
