Nurse , II or III

This job may be filled at either of the levels listed below.

Nurse I
- Min: $27.86/hr max: $34.82/hr nurse II
- Min: $33.35/hr max: $42.51/hr nurse III
- Min: $76,663.25/yr.

Max: $97,740.77/yr.

This is an entry level nursing position for nurses who can demonstrate the ability to work efficiently under the direct supervision of the Nursing Supervisor, correctly applying PEHP policies and principles, following through on assignments, and communicating professionally and effectively with providers and members.

The Nurse must always demonstrate judgment, high integrity, and personal values consistent with the company’s standards. The position involves identifying and coordinating the healthcare needs of PEHP members within a variety of programs and departments with the goal of providing high-quality, cost-effective outcomes.

• Identifies and performs utilization review of selected cases. Identifies needs based on clinical presentation, claims history, discussion with member and provider. Minimizes the use of out of network, out of state or unnecessary services.
• Logs authorized services/fees on the computer system. Ensures that information is current, accurate and easily understood by claims adjusters and customer service.
• Verifies medical diagnosis, status of current condition(s), and specific needs/treatment plan by reviewing the electronic medical record, past claims history to determine information that may affect the current treatment plan. Facilitates smooth delivery of case management services.
• Assists adjusters, if necessary, to match authorized services and negotiated fees with the claims received.
• Interprets clinical information to assess implications for treatment and applies PEHP Clinical Policy and Master Policy. Effectively communicates the decision to members and providers.
• Assists Clinical Service Reps with questions and complex issues regarding medical necessity and appropriateness of services and preauthorization.
• Maintains regular and reliable attendance.
• Maintains strict confidentiality.
• Performs other related duties as required.

Currently licensed and in good standing as a Registered Nurse (RN). New graduates may apply.

Currently licensed and in good standing as a Licensed Practical Nurse (LPN) with a minimum of one (1) year of medical experience in a broad spectrum of direct patient care and utilization review; or an equivalent combination of education and experience.

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.

Certification in Managed Care Nursing (CMCN) or Certified Case Manager (CCM) preferred.

Certified Professional Coder (CPC) preferred.

Currently licensed (or license eligible) as a Registered Nurse (RN) in the State of Utah, in good standing, with at least three (3) years 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 Health Edge, Health Rules, Payor, and Health Rules Care Manager is/are preferred.