Utilization Management and Population Health Nurse

Job Responsibilities

• Utilize 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.

Qualifications

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