Medical Management - Utilization Management RN 145-2019

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 80,000 - 100,000; Full time

Job summary

CommunityCare HMO Inc. seeks a Registered Nurse to join the Utilization Management team.

You will review clinical requests and assess opportunities for coordination of care to support overall membership, including high-risk and institutionalized populations, working as an active member of the Utilization Management Team. The role requires Oklahoma RN licensure, nursing degree, and experience in acute care and population health.

Qualifications

• RN license in Oklahoma and nursing degree required or equivalent.
• Experience with discharge planning or case management preferred.
• 3+ years of acute care experience preferred; 2+ years in population health preferred.
• Managed care exposure is a plus.
• Strong communication and documentation skills required.

Responsibilities

• Perform utilization review of outpatient, ancillary, inpatient, and post-acute services as indicated.
• Determine medical necessity and appropriateness using clinical criteria.
• Document all determinations and contact providers/members within established timeframes.
• Refer cases not meeting criteria to Medical Director.
• Flag quality issues to Medical Management leadership.
• Identify potential cases for Care Management programs.
• Collaborate with physicians and providers to coordinate care across the health care continuum.
• Perform accurate data entry and maintain records.
• Share necessary information with staff as required.
• Participate in continuing education initiatives.
• Collaborate with other departments as needed.
• Perform other assigned duties.

Skills

Managed care knowledge

Strong communication

Clinical judgment

Organizational skills

Documentation skills

Microsoft Office

Time management

Background check clearance

Education

Bachelor's degree in Nursing

Active Oklahoma RN license

Discharge planning or case management experience

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