Health Care Management Nurse III
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What you'll do
- Monitor the HCMU Medical box in Aerial, complete reviews, and upload documents in a timely manner.
- Coordinate exception requests, communicate outcomes with patients and providers, and participate in pharmacy and medical appeals.
- Protect the privacy and confidentiality of program participants' information, undergo annual HIPAA training, and review compliance programs with employees under direct supervision.
- Conduct clinical record audits to ensure provider compliance with the HealthChoice plan, prepare detailed reports, and communicate findings with providers and senior leadership.
- Review and assist in making fair determinations on second-level appeals in collaboration with the CMO and other healthcare professionals.
What they're looking for
- Possession of a valid permanent Oklahoma license as a registered nurse as approved by the Oklahoma Board of Nursing, OR Registered Nurse License recognized by the Enhanced Nurse Licensure Compact (eNLC)
- 6 years of professional nursing experience, including 3 years in a managed care or home health care program.
- Resume/CV with complete work and education history
Nice to have
- Certifications in any of the following areas: Certified Case Manager (CCM), Certified Fraud Examiner (CFE), Certified Professional in Healthcare Quality (CPHQ), Lean Six Sigma certification, Wound Care Certification (WCC)
- Advanced degree in Nursing, Healthcare Administration, or a related field
Summarised by NextRaise from the employer’s description, which follows in full below.
Full description from employer
Job Posting Title
Health Care Management Nurse IIIAgency
807 HEALTH CARE AUTHORITYSupervisory Organization
Medical GuidelinesJob Posting End Date
Refer to the date listed at the top of this posting, if available. Continuous if date is blank.
Note: Applications will be accepted until 11:59 PM on the day prior to the posting end date above.
Estimated Appointment End Date (Continuous if Blank)
Full/Part-Time
Full timeJob Type
RegularCompensation
$84,990/yearWhy You’ll Love Working Here
At the Oklahoma Health Care Authority (OHCA), your work matters. Every day, our team helps ensure Oklahomans have access to better health and better care. Guided by our core values, Passion for Purpose, Trust & Transparency, Empowerment & Accountability, Best-in-Class, Outcome-Driven, and Servant Leadership, we foster a workplace where people feel supported, respected, and empowered to make an impact. Learn more about OHCA.
Let’s Talk Benefits
We know your great work deserves great support. Here’s a snapshot of what we offer for all eligible employees.
Generous state-paid benefit allowance to offset insurance premiums.
A wide selection of insurance plans with no pre-existing condition exclusions.
Flexible Spending Accounts for health care and dependent care.
Retirement Savings Plan with employer contributions.
11 paid holidays annually.
15 days of vacation and 15 days of sick leave in the first year.
Longevity Bonus recognizing years of public service.
Public Service Loan Forgiveness eligibility and tuition reimbursement.
Wellness benefits, including an on-site gym and fitness center discounts.
Job Description
Location: 4345 N Lincoln Blvd, Oklahoma City, OK 73105
Salary: $84,990/year
Work Schedule: Monday – Friday
Primary Hours: 8:00 a.m. – 5:00 p.m.
Agency/Division Information
The Oklahoma Health Care Authority (OHCA) works to ensure Oklahomans have access to better health and better care. The agency’s core values include passion for purpose, trust and transparency, empowerment and accountability, best in class and outcome-driven, and servant leadership. As part of the interview process, candidates may be required to attend an in-person interview at our Oklahoma City office.
Position Purpose:
The Health Care Management Nurse III is responsible for overseeing case management processes, analyzing data for potential fraud, waste, and abuse, ensuring compliance with HIPAA and organizational policies, conducting provider audits, and managing second-level appeals. This role involves close coordination with medical directors, legal teams, and other healthcare professionals to ensure the accuracy, professionalism, and efficiency of health care management operations.
Essential Functions May Include:
Monitor the HCMU Medical box in Aerial, complete reviews, and upload documents in a timely manner. Coordinate exception requests, communicate outcomes with patients and providers, and participate in pharmacy and medical appeals.
Protect the privacy and confidentiality of program participants' information, undergo annual HIPAA training, and review compliance programs with employees under direct supervision.
Conduct clinical record audits to ensure provider compliance with the HealthChoice plan, prepare detailed reports, and communicate findings with providers and senior leadership.
Review and assist in making fair determinations on second-level appeals in collaboration with the CMO and other healthcare professionals.
Other duties as assigned.
Knowledge, Skills, Abilities and Competency Requirements
The Knowledge, Skills, and Abilities (KSAs) for the Health Care Management Nurse III include a deep understanding of HIPAA, fraud prevention, and healthcare compliance, knowledge of case management processes and tools (such as Aerial and OnBase), and the ability to analyze data for fraud detection and audit purposes. Strong communication, conflict resolution, and decision-making skills are crucial, alongside meticulous attention to detail in audits and documentation.
Two Korn Ferry competencies that best align with this position are "Manages Conflict" and "Decision Quality," as both are vital for handling case management, provider audits, and making sound decisions on appeals.
**To be considered for this position your application must include a resume/CV with complete work and education history.**
Education and/or Experience:
Possession of a valid permanent Oklahoma license as a registered nurse as approved by the Oklahoma Board of Nursing,
OR
Registered Nurse License recognized by the Enhanced Nurse Licensure Compact (eNLC),
AND
6 years of professional nursing experience, including 3 years in a managed care or home health care program.
Preference Qualifications Include:
Certifications in any of the following areas: Certified Case Manager (CCM), Certified Fraud Examiner (CFE), Certified Professional in Healthcare Quality (CPHQ), Lean Six Sigma certification, Wound Care Certification (WCC)
Advanced degree in Nursing, Healthcare Administration, or a related field
Physical Demands and Work Environment
Work is typically performed in an office setting with climate-controlled settings and exposure to moderate noise levels. In the course of performing job duties, employees are required to speak, stand, walk, and reach with their hands and arms. This position requires extended periods of sitting and daily use of computers and phones. Employees must be willing to complete all job-related travel associated with this position. Being present at the office is an essential function of this position.
Accommodation Statement
The Oklahoma Health Care Authority complies with applicable State and Federal civil rights laws and does not discriminate. All qualified applicants will receive consideration for employment without regard to race, color, sex, religion, disability, age, national origin, or genetic information. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact the Civil Rights Coordinator at 405-522-7335.
Notice to applicants:
Please add OHCAHR@okhca.org to the address book or “safe-senders” list in your email. All correspondence will come from this address. Be sure to check your junk folder. If you have questions about the status of your application, you can contact the HR team at 405-522-7093.
Note: Applications will be accepted until 11:59 PM on the day prior to the posting end date above.
Current State of Oklahoma employees must apply for open positions internally through Workday Jobs Hub.
Equal Opportunity Employment
The State of Oklahoma is an equal opportunity employer and does not discriminate on the basis of genetic information, race, religion, color, sex, age, national origin, or disability.
Current active State of Oklahoma employees must apply for open positions internally through the Workday Jobs Hub.
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