Log In
Sign Up
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.
Job Description
This job may be filled at any of the levels listed below.
Nurse II- Min: $31.74/hr. Max: $40.47/hr
Nurse III- Min: $72,970.92/yr. Max: $93,033.28/yr.
ESSENTIAL DUTIES & RESPONSABILITIES
• Reviews claims data to identify cases of excess or inappropriate utilization. Identifies needs based on clinical presentation, claims history, discussion with member and provider.
• Intervenes in identified cases in support of PEHP programs. Uses clinical knowledge, current benefits, and community resources to coordinate site of service, utilization of emergency room and primary care services, post discharge plans, mental health and other services with members and providers. Minimizes the use of out of network benefits.
• Documents activities in PEHP systems. Maintains files to ensure that information is current, accurate and easily understood.
• Reviews recommendations for alternative benefits with the appropriate supervisor for approval.
• Assists adjusters to match authorized services and negotiated fees with the claims received.
• Provides outcome and cost saving reporting.
• Serves as a resource for PEHP staff especially Member Services, Appeals and Policy Management, Clinical Improvement and Clinical Management staff members. Responds to inquiries and communicates PEHP policy.
• Interprets clinical information to assess implications for treatment and applies PEHP policy. Effectively communicates the decision to members, providers and PEHP staff.
• Audits select claims to verify services were ordered, received and paid appropriately.
• Maintains strict confidentiality in compliance with all applicable federal and state law and internal policies.
• Performs other related duties as required.
Required Experience
Nurse II
Currently licensed and in good standing as a Registered Nurse (RN) and a minimum of three (3) years OR currently licensed and in good standing as a Practical Nurse (LPN) with a minimum of nine (9) years of combined experience in a broad spectrum of nursing, utilization review, and/or medical case management.
CMCN or CCM certificate preferred.
CPC preferred.
Nurse III
Currently licensed (or license eligible) as a Registered Nurse in the State of Utah, in good standing, with at least three (3) years of case management experience or five (5) years of clinical experience; or an equivalent combination of education and experience.
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 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.
