Medical Management - Utilization Management RN 145-2011

CommunityCare, Inc.; Tulsa, Northern (OK, KY); Hybrid; USD 70,000 - 90,000; Full time

Job summary

CommunityCare, Inc. in Tulsa, OK is seeking a Registered Nurse to perform clinical review of utilization requests and implement care coordination opportunities for at‑risk members.

You will be part of the Utilization Management Team, collaborating with physicians and other providers to ensure medical necessity and appropriate care across the health care continuum. This role requires Oklahoma RN license and 3 years acute care experience; managed care knowledge and strong documentation skills are

Qualifications

• Bachelor of Science in Nursing from an accredited program.
• Active, unrestrictive Oklahoma RN license.
• Three years acute care experience preferred.
• Two years population health experience preferred.
• Managed care knowledge and strong documentation skills.

Responsibilities

• Performs utilization review of outpatient and inpatient services.
• Determines medical necessity using clinical criteria.
• Documents review determinations and communicates with providers/members.
• Refers cases not meeting criteria to Medical Director.
• Identifies quality issues and refers to Medical Management leadership.
• Collaborates with physicians to coordinate care across the continuum.
• Participates in continuing education and cross‑department collaboration.
• Performs other duties as assigned.

Skills

Managed care knowledge

Communication skills

Time management

Clinical reasoning

Education

Bachelor of Science in Nursing

Oklahoma RN license

Tools

Microsoft Office

Job description

Tulsa, OK, USA

Job Description

JOB SUMMARY:

Responsible for clinical review of utilization requests and assessment and implementation of potential coordination of care opportunities for overall membership, institutionalized populations, high risk members, and other members identified with at risk or high utilization needs. Functions as an active team member of the Utilization Management Team.

KEY RESPONSIBILITIES:

• Performs utilization review of outpatientand ancillary services as well as inpatient and post-acute services when indicated.
• Determines medical necessity and appropriateness of services using clinical review criteria.
• Accurately documents all review determinations and contacts providers and members according to established timeframes.
• Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director.
• Appropriately identifies and refers quality issues to Medical Management leadership.
• Appropriately identifies potential cases for Care Management programs.
• Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum.
• Communicates appropriate information to other staff members as necessary/required.
• Participates in continuing education initiatives.
• Collaborates with other departments as needed.
• Performs other duties as assigned.

QUALIFICATIONS:

• Knowledge of managed care and associated group benefit plans.
• Possess strong oral and written communication skills.
• Ability to reason logically and to use good judgment when interpreting materials or situations.
• Knowledge of community- based resources.
• Must have excellent organizational skills and be able to perform multiple tasks.
• Proficient in Microsoft applications.
• Excellent time management and documentation skills.
• Successful completion of Health Care Sanctions background check.

EDUCATION/EXPERIENCE:

• Graduation from accredited School of Nursing.
• Current, active, unrestrictive license to practice as a Registered Nurse in the State of Oklahoma.
• Three years of acute care experience preferred.
• Two years of experience working with population health preferred.
• Managed care experience a plus.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin