Health Care Management Nurse III

Job Title

Health Care Management Nurse III

807 HEALTH CARE AUTHORITY

Medical Guidelines

Refer to the date listed at the top of this posting, if available. Continuous if date is blank.

Note:

Applications will be accepted until 11:59 PM on the day prior to the posting end date above.

Full time

Regular

$84,990/year

At the Oklahoma Health Care Authority (OHCA), your work matters. Every day, our team helps ensure Oklahomans have access to better health and better care. Guided by our core values,
Passion for Purpose, Trust & Transparency, Empowerment & Accountability, Best-in-Class, Outcome-Driven, and Servant Leadership
, we foster a workplace where people feel supported, respected, and empowered to make an impact. Learn more about OHCA.

• Generous state-paid benefit allowance to offset insurance premiums.
• A wide selection of insurance plans with no pre-existing condition exclusions.
• Flexible Spending Accounts for health care and dependent care.
• Retirement Savings Plan with employer contributions.
• 11 paid holidays annually.
• 15 days of vacation and 15 days of sick leave in the first year.
• Longevity Bonus recognizing years of public service.
• Public Service Loan Forgiveness eligibility and tuition reimbursement.
• Wellness benefits, including an on-site gym and fitness center discounts.

Location:

4345 N Lincoln Blvd, Oklahoma City, OK 73105

Salary: $84,990/year

Work Schedule:

Monday – Friday

Primary

Hours:

8:00 a.m. – 5:00 p.m.

The Oklahoma Health Care Authority (OHCA) works to ensure Oklahomans have access to better health and better care. The agency’s core values include passion for purpose, trust and transparency, empowerment and accountability, best in class and outcome-driven, and servant leadership. As part of the interview process, candidates may be required to attend an in-person interview at our Oklahoma City office.

The Health Care Management Nurse III is responsible for overseeing case management processes, analyzing data for potential fraud, waste, and abuse, ensuring compliance with HIPAA and organizational policies, conducting provider audits, and managing second-level appeals. This role involves close coordination with medical directors, legal teams, and other healthcare professionals to ensure the accuracy, professionalism, and efficiency of health care management operations.

• Monitor the HCMU Medical box in Aerial, complete reviews, and upload documents in a timely manner. Coordinate exception requests, communicate outcomes with patients and providers, and participate in pharmacy and medical appeals.
• Protect the privacy and confidentiality of program participants' information, undergo annual HIPAA training, and review compliance programs with employees under direct supervision.
• Conduct clinical record audits to ensure provider compliance with the Health Choice plan, prepare detailed reports, and communicate findings with providers and senior leadership.
• Review and assist in making fair determinations on second-level appeals in collaboration with the CMO and other healthcare professionals.
• Other duties as assigned.

The Knowledge, Skills, and Abilities (KSAs) for the Health Care Management Nurse III include a deep understanding of HIPAA, fraud prevention, and healthcare compliance, knowledge of case management processes and tools (such as Aerial and OnBase), and the ability to analyze data for fraud detection and audit purposes. Strong communication, conflict resolution, and decision-making skills are crucial, alongside meticulous attention to detail in audits and…