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. 

• 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 

Notice to applicants:

Please add [email protected]  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.