Medical Management - Utilization Management RN 145-2016

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 65,000 - 90,000; Full time

Job summary

CommunityCare HMO Inc. is seeking a Registered Nurse to join the Utilization Management Team. You will review utilization requests, assess potential coordination of care opportunities for the membership, high-risk populations, and other at-risk members, and implement appropriate care pathways.

You will collaborate with physicians and other providers, document determinations, participate in continuing education, and support quality initiatives across the health care continuum.

Qualifications

• Graduate of an accredited School of Nursing.
• Current, active Oklahoma RN license.
• Three years of acute care experience preferred.
• Two years of population health experience preferred.
• Discharge planning or case management experience preferred.
• Managed care experience a plus.

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.
• Documents all review determinations and contacts providers and members according to established timeframes.
• Identifies and refers cases that do not meet established clinical 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 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.

Skills

Knowledge of managed care

Strong communication skills

Analytical reasoning

Knowledge of community resources

Organizational skills

Microsoft Office proficiency

Time management

Background check compliance

Education

Accredited School of Nursing graduate

Oklahoma RN license (active)

Acute care experience (3+ years) preferred

Population health experience (2+ years) preferred

Discharge planning or case management experience preferred

Managed care experience a plus

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.

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