Medical Management - Utilization Management RN 145-2016

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 75,000 - 95,000; Full time

Job summary

CommunityCare HMO Inc. in Oklahoma seeks a Registered Nurse to perform utilization review and assess opportunities for coordination of care across the member population.

The role is part of the Utilization Management Team and requires collaboration with physicians and other providers to facilitate services across the health care continuum. The position emphasizes clinical review, documentation, and adherence to established criteria, with opportunities to contribute to Care Management programs

Qualifications

• Knowledge of managed care and related group benefit plans.
• Strong oral and written communication skills.
• Ability to reason logically and use good judgment.
• Knowledge of community-based resources.
• Excellent organizational and multitasking abilities.
• Proficiency in Microsoft applications.
• Strong time management and documentation skills.
• Health Care Sanctions background check completed.

Responsibilities

• Perform utilization review of outpatient, ancillary, inpatient and post-acute services.
• Determine medical necessity using clinical criteria.
• Document all review determinations and contact providers/members timely.
• Refer cases not meeting criteria to Medical Director.
• Identify quality issues and refer to Medical Management leadership.
• Identify potential Care Management opportunities.
• Collaborate with physicians and providers to coordinate care.
• Perform accurate data entry.
• Communicate information to staff as required.
• Participate in continuing education and cross-department collaboration.
• Perform other duties as assigned.

Skills

Managed care knowledge

Oral and written communication

Judgment and reasoning

Organizational skills

Microsoft Office

Time management and documentation

Team collaboration

Education

RN license in OK

BSN preferred

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.

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 outpatient and 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.

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