Medical Management - Utilization Management RN 145-2016

CommunityCare, Inc.; Tulsa (OK); On-site; USD 70,000 - 90,000; Full time

Job summary

CommunityCare, Inc. seeks a highly organized Registered Nurse to lead utilization review and coordinate care for at-risk members in Oklahoma. The role focuses on evaluating outpatient, inpatient, and post-acute services and ensuring medical necessity per criteria.

With collaboration across physicians and care teams, you will document determinations, identify cases for Care Management, and participate in ongoing education to improve member outcomes. Acute care experience preferred.

Qualifications

• Knowledge of managed care and associated group benefit plans.
• 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.
• Excellent organizational skills and ability to perform multiple tasks.
• Proficient in Microsoft applications.
• Excellent time management and documentation skills.
• Successful completion of Health Care Sanctions background check.

Responsibilities

• Performs utilization review of outpatient, ancillary, inpatient, and post-acute services when indicated.
• Determines medical necessity and appropriateness of services using clinical review criteria.
• Documents all review determinations and contacts providers and members timely.
• Identifies and refers cases that do not meet criteria to the Medical Director.
• Identifies and refers quality issues to Medical Management leadership.
• Identifies potential cases for Care Management programs.
• Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum.
• Performs accurate data entry.
• Communicates information to staff; participates in continuing education initiatives.
• Collaborates with other departments; performs other duties as assigned.

Skills

Managed care knowledge

Communication skills

Judgment

Community resources knowledge

Organizational skills

Microsoft Office

Time management

Documentation skills

Education

Nursing degree

Registered Nurse license in OK

Tools

Microsoft Office

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.
• Performs accurate data entry.
• 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.
• Previous discharge planning or case management experience preferred.
• Managed care experience a plus.