Nurse III - Clinical Management

About The Company

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.

Job Description

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

Required Experience

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.