RN Care Specialist I

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RN Care Specialist I

Department: Health Care Services

FLSA Status: Full Time, Exempt

Salary Level: 7

**This position is eligible to work from home upon management's approval**

Position Summary:

UHA’s RN Care Specialist I bridge the gap between administrative needs, data driven imperatives and the clinically relevant needs of our members. Nurses must emphasize these issues (access, quality, safety, statutory medical necessity, and attention to chronic disease) with alacrity and special attention to vulnerable populations while using clinical knowledge and judgment to align resources with member needs. This position effectively coordinates patient care/unit activities among the HCS department, nursing peers, and physicians.

Essential Duties & Responsibilities:

• Performs utilization management and care coordination for less complex cases according to existing guidelines, policies and procedures, while acquiring the necessary competencies for handling complex cases under the direct supervision of the department clinical leadership.
• Performs less complex needs assessments, discharge planning and follow-up care coordination for members being discharged from inpatient care as identified through concurrent review (CCR), prior authorization, or other means
• Performs less complex utilization management reviews and/or care management while exercising clinical judgment regarding quality, safety and medical necessity within required time frames, and according to the Institute of Medicine STEEEP principles: Safe, Timely, Effective, Efficient, Equitable, Patient Centered.
• Documents clinical review information, prior authorizations data, MCTNs, LOAs and associated materials in QNXT, online PA, CM module, and on spreadsheets
• Facilitates access to care, taking into consideration the member’s culture, language, transportation, housing, and financial condition that may impact health, using the MBG, medical payment policies, and community resources appropriately
• Acts as a clinical resource and ensures availability in person or by phone to non-clinical staff during business hours.
• Promotes PCMH for members with complex health needs.
• Participates in policy and benefit development, quality improvement programs, processes, or interdepartmental committees as assigned
• Conversant with URAC standards and timelines for Utilization Management
• Promotes member self-management through motivational interviewing and shared decision making.
• Confers with nursing leadership and medical directors as necessary for any quality or safety issues identified through the course of the reviews to discuss actions necessary to further patient safety and all elements of the triple aim (improving the patient experience of care (including quality and satisfaction, improving the health of the patient; and reducing the cost of healthcare).
• Health Care Services will invest in reasonable training in UM/CM so as to assist a registered nurse who has the appropriate aptitude to achieve proficiency in this field of nursing. This serves the dual purposes of passing the advanced skills of current UHA professionals to new nurses AND to cultivate fresh insights and energies for the company. UHA’s interest in these purposes means that ongoing learning, independence and excellence must be acquired with alacrity.
• Maintains confidentiality at all times
• Reports irregularities in claims submitted, member eligibility for benefit coverage, or situations that requires further review
• Strong teamwork skills, taking initiative to share knowledge with all team members
• Strong critical thinking and problem-solving skills

Required Education and Experience:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Able to navigate through internal and external computer systems including Microsoft Word and Excel, and have proficient PC keyboarding skills
• Practice strong assessment and critical thinking skills and are able to multi-task in today’s demanding nursing industry
• New graduates are encouraged to apply
• Unrestricted, valid, and active RN License for the State of Hawaii.
• Possess excellent interpersonal skills and are able to work cohesively with the entire Nursing / Administrative team
• Nursing Diploma or Associate degree in nursing from an accredited nursing program, college or university; Bachelor’s Degree in Nursing or related field from an accredited college or university preferred
• Valid driver’s license and proof of automobile insurance in accordance with UHA required minimums

Preferred and Advanced Qualifications:

• Prior work experience in a similar role in care and/or utilization management preferred
• Familiar with ICD-9/10 and CPT coding desirable
• Knowledge of QNXT system desirable
• Certification in Utilization Review or Care Management desirable
• Other related specialized certification, desirable
• Familiar with health insurance benefit management, community resources, and evidence-based medical guidelines

Physical Demands/Working Conditions:

The work environment characteristics described here are representative of those associate encounters while performing the essential functions of this job.

• Able to drive an automobile as needed to travel to hospitals on Oahu and, if necessary by airplane to the outer islands
• Requires frequent standing, walking, sitting, stooping, walking, seeing, hearing and speaking
• Daily use of a computer keyboard, mouse and viewing of a computer monitor
• Requires on-site visits at facilities, provider offices, or other settings
• Extended and weekend hours may be required, depending upon the workload

Vehicles

• Must have access to an automobile and be able to travel in automobile and plane

Work Location: Honolulu, HI - Only Hawaii resident will be considered

Competitive compensation & excellent benefits offered

Visit our website at https://uhahealth.com/page/career-opportunities to apply and for details about vacant positions.

An Equal Opportunity Employer