RN Utilization Management Specialist

CommunityCare, Inc.; Tulsa (OK); On-site; USD 65,000 - 86,000; Full time

Job summary

CommunityCare, Inc. is seeking a Registered Nurse to review utilization requests and coordinate care for members, including high-risk populations.

You will be part of the Utilization Management Team, applying clinical criteria to determine medical necessity and documenting all determinations. Responsibilities include reviewing outpatient, inpatient, and post-acute services; partnering with physicians and care teams; identifying cases for Care Management; and ensuring timely communication and

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.
• Documents all review determinations and contacts providers and members according to established timeframes.
• 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

Managed care knowledge

Oral and written communication

Analytical reasoning

Community resources knowledge

Organizational skills

Microsoft Office

Time management & documentation

Health Care Sanctions background check

Education

Registered Nurse license in Oklahoma

Graduation from accredited School of Nursing

Job description

CommunityCare, Inc. is seeking a Registered Nurse to review utilization requests and coordinate care for members, including high-risk populations.

You will be part of the Utilization Management Team, applying clinical criteria to determine medical necessity and documenting all determinations. Responsibilities include reviewing outpatient, inpatient, and post-acute services; partnering with physicians and care teams; identifying cases for Care Management; and ensuring timely communication and