Utilization Management and Population Health Nurse

* 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