Utilization Management and Population Health Nurse

Job Title

Utilization case review and application of criteria to approve initial and continued inpatient services

Identify patients in need of outreach efforts based on patient risk stratification or other defined criteria as well as defined disease management guidelines

Work with CPHO team, patient's Primary Care Physician and all other providers of the patients' care to develop individualized care plans

Facilitate communication with patients and care team, coordinate referrals, and promote optimal allocation of available resources

Measure progress toward goals based on clinical judgment, review of patients' self-monitoring tools and trends in clinical data

Assess and monitor adherence to outreach and then problem-solve intrinsic and extrinsic barriers to effective patient self-management of chronic conditions

Provide educational materials and resources to patient/family and their care providers

Refer patients/families to self-management support programs as needed and communicate with care providers to ensure safe and effective care management

Analyze clinical data to track patient outcomes to determine improvement

Triage patient phone calls for acute patient issues and counsel accordingly

Oversight and management of population health quality improvement studies to reach established targets

Interface with Commercial and Government entities on care coordination, HEDIS and other QI activities

Report to UM/QM Committee on progress toward goals and make recommendations for improvement

Other duties as assigned

Minimum qualifications must be health plan requirements, including but not limited to licensure/certification, as applicable

Bachelors or better

RN License

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