RN Care Specialist I

4 days ago

Honolulu, Hawaii, United States UHA Full time
UHA RN Care Specialist I Job Description

We are seeking a highly skilled RN Care Specialist I to join our team at UHA. As a key member of our Health Care Services department, you will play a critical role in bridging the gap between administrative needs, data-driven imperatives, and clinically relevant needs of our members.

Key Responsibilities:
  • Perform utilization management and care coordination for less complex cases according to existing guidelines, policies, and procedures.
  • Conduct less complex needs assessments, discharge planning, and follow-up care coordination for members being discharged from inpatient care.
  • Exercise clinical judgment regarding quality, safety, and medical necessity within required time frames, and according to the Institute of Medicine STEEEP principles.
  • Document clinical review information, prior authorizations data, MCTNs, LOAs, and associated materials in QNXT, online PA, CM module, and on spreadsheets.
  • Facilitate access to care, taking into consideration the member's culture, language, transportation, housing, and financial condition that may impact health.
  • Act as a clinical resource and ensure availability in person or by phone to non-clinical staff during business hours.
  • Promote PCMH for members with complex health needs.
  • Participate in policy and benefit development, quality improvement programs, processes, or interdepartmental committees as assigned.
Requirements:
  • Able to navigate through internal and external computer systems, including Microsoft Word and Excel, and have proficient PC keyboarding skills.
  • Practice strong assessment and critical thinking skills and are able to multi-task in today's demanding nursing industry.
  • Unrestricted, valid, and active RN License for the State of Hawaii.
  • Possess excellent interpersonal skills and are able to work cohesively with the entire Nursing/Administrative team.
  • Nursing Diploma or Associate degree in nursing from an accredited nursing program, college, or university; Bachelor's Degree in Nursing or related field from an accredited college or university preferred.
Preferred Qualifications:
  • Prior work experience in a similar role in care and/or utilization management preferred.
  • Familiar with ICD-9/10 and CPT coding desirable.
  • Knowledge of QNXT system desirable.
  • Certification in Utilization Review or Care Management desirable.

We offer competitive compensation and excellent benefits. If you are a motivated and detail-oriented RN with a passion for delivering high-quality patient care, we encourage you to apply for this exciting opportunity.

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