Medical Management - Utilization Management RN 145-2016

Community Care; United States; Remote; USD 85,000 - 110,000; Full time

Job summary

Community Care is seeking a Registered Nurse to perform utilization review and coordinate care for members across the health care continuum. You will assess medical necessity, document decisions, and collaborate with physicians and care teams to optimize outcomes.

In this role, you will review outpatient, inpatient, and post-acute services, communicate findings to providers, and participate in quality improvement initiatives.

Qualifications

• Must possess an active RN license in Oklahoma.
• Graduation from an accredited School of Nursing is required.
• Knowledge of managed care and related benefit plans is essential.
• Strong communication and documentation skills.
• Proficiency with Microsoft Office and EHR systems.

Responsibilities

• Performs utilization review of outpatient, ancillary, inpatient and post-acute services.
• Determines medical necessity and appropriateness of services.
• Documents all review determinations and communicates with providers and members.
• Identifies and refers cases not meeting criteria to Medical Director.
• Collaborates with physicians to facilitate care across the health care continuum.
• Performs accurate data entry and communicates information to staff.

Skills

Utilization review

Communication skills

Organizational skills

Time management

Documentation skills

Microsoft Office proficiency

Education

Registered Nurse license (Oklahoma)

Graduate from accredited School of Nursing

Tools

Microsoft Office Suite

Electronic Health Records

Utilization management software

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 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.