RN Care Specialist

Job Description

Job Description

JOIN UHA’S TEAM

We focus on your health and pay 100% for your family's medical insurance and provide 20 days of paid personal time off during your first year!

Department: Health Care Services
Reports To: Clinical Care Manager
FLSA Status: Full-Time, Exempt
Salary Range: $78,301 - $101,791

Position Summary :

UHA’s RN Care Specialist bridges 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 according to existing guidelines, policies and procedures, while acquiring the necessary competencies for handling complex cases. with access to clinical leadership support and medical director consultation as needed.
  • Performs needs assessments, discharge planning and follow-up care coordination for members being discharged from inpatient care as identified through concurrent review (CR), prior authorization (PA), claim reviews, or other means.
  • Performs 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, member cost transparency notices (MCTN), letters of agreement (LOA) and associated materials in QNXT, Online PA, CM Module, and other required tracking and documentation tools.
  • Makes determinations within established clinical criteria and policies and appropriately escalates cases that do not meet criteria to Medical Directors or clinical leadership.
  • 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 patient centered medical homes (PCMH) and enhanced access to care 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 needed, regarding any quality or safety issues identified during reviews to discuss actions necessary to enhance patient safety and support all elements of the Triple Aim (improving the patient experience of care, including quality and satisfaction; improving patient health; and reducing the cost of healthcare).
  • Always maintain confidentiality.
  • Identifies and reports irregularities related to claims, clinical documentation, medication utilization, member eligibility, or other matters requiring further review.
  • Demonstrates working knowledge of UHA benefits and policies to support accurate prior authorization, utilization management, and care management activities when communicating with members and providers.
  • Participates in the development, review, and revisions of Health Care Services educational materials, Medical Payment Policies, and other documentation, including collaboration with other departments as necessary.
  • Demonstrates strong critical thinking, problem-solving, and teamwork skills, including proactively sharing clinical knowledge with team members.
  • Expected to work on‑site at a UHA office location or other designated locations for meetings, training, scheduled work hours, and other business‑related activities. While some roles may be eligible for remote or hybrid work, this position may require full‑time, permanent on‑site work based on business needs.

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
  • Demonstrates strong assessment and critical thinking skills with the ability to manage multiple priorities in a fast‑paced clinical environment.
  • New graduates with strong clinical judgment, adaptability, and interest in utilization or care management will be considered.
  • Unrestricted, valid, and current RN License for the State of Hawaii. Demonstrate strong interpersonal skills and collaborate effectively with the Nursing and Administrative teams.
  • Nursing Diploma or Associate degree in nursing from an accredited nursing program, college or university
  • Valid driver’s license and proof of automobile insurance in accordance with UHA required minimums (see Use Of Personal Or Rental Vehicles And Mileage Reimbursement Policy number A-012 in the UHA Policy and Procedure Manual)

Preferred and Advanced Qualifications:

• Bachelor’s degree in nursing or related field from an accredited college or university
• Experience working in a health plan, managed care organization, case management or utilization management environment 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
• This position may eligible to work from home or work a hybrid position upon manager’s approval

Equipment and Software Use

Please refer to Associate Handbook – Employment Policies – Position Descriptions for general list of equipment for that applies to all positions

Vehicles

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

Competitive compensation & excellent benefits offered

Visit our website at -opportunities to apply and for details about vacant positions.

An Equal Opportunity Employer