RN Care Specialist I

6 days ago


Honolulu, Hawaii, United States UHA Full time
Job Summary

UHA is seeking a skilled RN Care Specialist I to bridge the gap between administrative needs, data-driven imperatives, and clinically relevant needs of our members. As a key member of our Health Care Services team, you will coordinate patient care/unit activities among nursing peers, physicians, and other stakeholders.

Key Responsibilities
  • Perform utilization management and care coordination for less complex cases, acquiring necessary competencies for handling complex cases under supervision.
  • 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, adhering to Institute of Medicine STEEEP principles.
  • Document clinical review information, prior authorizations, and associated materials in QNXT, online PA, CM module, and spreadsheets.
  • Facilitate access to care, considering member culture, language, transportation, housing, and financial condition that may impact health.
  • Act as a clinical resource, ensuring availability to non-clinical staff during business hours.
  • Promote Patient-Centered Medical Home (PCMH) for members with complex health needs.
  • Participate in policy and benefit development, quality improvement programs, and interdepartmental committees as assigned.
Requirements
  • Unrestricted, valid, and active RN License for the State of Hawaii.
  • Nursing Diploma or Associate degree in nursing from an accredited nursing program, college, or university; Bachelor's Degree in Nursing or related field preferred.
  • Valid driver's license and proof of automobile insurance in accordance with UHA required minimums.
  • Prior work experience in a similar role in care and/or utilization management preferred.
Preferred Qualifications
  • Familiarity with ICD-9/10 and CPT coding desirable.
  • Knowledge of QNXT system desirable.
  • Certification in Utilization Review or Care Management desirable.
Work Environment

The work environment characteristics described here are representative of those associates encounter while performing the essential functions of this job.

Able to drive an automobile as needed to travel to hospitals on Oahu and, if necessary, by airplane to the outer islands.

Requires frequent standing, walking, sitting, stooping, walking, seeing, hearing, and speaking.

Daily use of a computer keyboard, mouse, and viewing of a computer monitor.

Requires on-site visits at facilities, provider offices, or other settings.

Extended and weekend hours may be required, depending upon the workload.


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