Utilization Management and Population Health Nurse

Job Description

Job Description

• 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