Medical Management - Utilization Management RN 145-2026

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 70,000 - 100,000; Full time

Job summary

CommunityCare HMO Inc. in Oklahoma seeks an experienced Registered Nurse to lead utilization review for outpatient and inpatient services, and to assess and implement care coordination opportunities for members with high utilization.

The role emphasizes collaboration with physicians and care teams, accurate documentation, and adherence to clinical criteria. A valid Oklahoma RN license and 3+ years acute care experience are preferred.

Qualifications

• Knowledge of managed care and associated group benefit plans.
• 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.
• Excellent organizational skills and ability to perform multiple tasks.
• Proficient in Microsoft applications.
• Excellent time management and documentation skills.
• Successful completion of Health Care Sanctions background check.

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.

Skills

Utilization review

Nursing

Communication skills

Time management

Documentation

Microsoft Office

Clinical decision making

Education

RN license in Oklahoma

Bachelor of Science in Nursing

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.

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