Medical Management - Utilization Management RN 145-2016

CommunityCare, Inc.; Tulsa, Northern (OK, KY); Hybrid; USD 65,000 - 90,000; Full time

Job summary

CommunityCare, Inc. in Tulsa, OK is seeking a Registered Nurse to perform utilization review and coordinate care for high-risk members and populations served. The role collaborates with physicians, documents determinations, and supports care management initiatives across the health care continuum.

A Oklahoma RN license and acute care experience are preferred. Join a collaborative Utilization Management Team, participate in ongoing education, and ensure timely, quality patient care across

Qualifications

• Graduation from accredited School of Nursing.
• Current, active, unrestrictive RN license in Oklahoma.
• Three years acute care experience preferred.
• Two years population health 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 potential cases for Care Management programs and collaborates with physicians.
• 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.
• Performs other duties as assigned.

Skills

Communication skills

Judgment and decision making

Organizational skills

Time management

Documentation skills

Community resources knowledge

Managed care knowledge

Education

RN license in Oklahoma

Graduation from accredited School of Nursing

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