Utilization Management and Population Health Nurse
About The Position
The UM/Population Nurse is a health professional with an active, unrestricted Illinois professional license who is responsible for day-to-day utilization review activities. Within Care Coordination and Quality Improvement, the nurse oversees and manages care coordination and quality improvement activities for identified Century PHO enrollees. This includes identifying at-risk patients and helping them navigate the continuum of care to achieve optimal clinical outcomes. The role also supports utilization case review, individualized care planning, patient outreach and education, chronic-condition self-management, and population health quality improvement. The nurse collaborates with the CPHO team, primary care physicians, other providers, patients, and families, and reports progress and improvement recommendations to the UM/QM Committee.
Requirements
- Current RN licensure.
- Active, unrestricted Illinois professional license.
- Meet applicable health plan minimum qualifications, including licensure or certification requirements, as applicable.
Responsibilities
- Review utilization cases and apply criteria to approve initial and continued inpatient services.
- Identify patients who need outreach based on risk stratification, other defined criteria, or disease-management guidelines.
- Work with the CPHO team, patients’ primary care physicians, and other care providers to develop individualized care plans.
- Facilitate communication with patients and the care team, coordinate referrals, and promote optimal allocation of available resources.
- Measure progress toward goals using clinical judgment, patients’ self-monitoring tools, and trends in clinical data.
- Assess and monitor adherence to outreach, and address intrinsic and extrinsic barriers to effective self-management of chronic conditions.
- Provide educational materials and resources to patients, families, and care providers.
- Refer patients and families to self-management support programs as needed, and communicate with care providers to support safe and effective care management.
- Analyze clinical data to track patient outcomes and determine improvement.
- Triage patient phone calls about acute issues and counsel patients accordingly.
- Oversee and manage population health quality improvement studies to reach established targets.
- Interface with Commercial and Government entities on care coordination, HEDIS, and other quality improvement activities.
- Report progress toward goals to the UM/QM Committee and make recommendations for improvement.
- Perform other duties as assigned.
Benefits
- Medical, dental, and vision coverage for eligible employees.
- Employer-paid life and AD&D insurance for eligible employees.
- Flexible Spending Account options.
- 403(b) retirement plan with employer match, subject to eligibility requirements.
- Paid Time Off, which may increase with years of service.
- Employee discount at the Humboldt Park Health Wellness Center.
- Education reimbursement, subject to eligibility requirements.
- Employee wellness programs.
- Additional voluntary benefits.
- Opportunities for additional shifts, where applicable.
- Retirement planning support.
- Opportunities for continued growth and development.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
