Utilization Management RN: Care Coordination Pro

Santa Barbara Cottage Hospital; United States; Remote; USD 70,000 - 110,000; Full time

Job summary

Santa Barbara Cottage Hospital is seeking a registered nurse to perform utilization review of inpatient, outpatient, and post-acute services. The role involves determining medical necessity, documenting decisions, and coordinating with the Medical Director and care management teams to ensure appropriate care across the health care continuum.

Responsibilities include data entry, interdepartmental communication, and ongoing participation in education initiatives.

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.

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

Managed care knowledge

Communication skills

Analytical reasoning

Community resources knowledge

Organizational skills

Microsoft Office

Time management

Documentation skills

Health Care Sanctions background check

Education

Graduation from accredited School of Nursing

Current, active RN license in Oklahoma

Three years of acute care experience preferred

Two years of population health experience preferred

Discharge planning or case management experience preferred

Managed care experience a plus

Tools

Microsoft Office

Job description

Santa Barbara Cottage Hospital is seeking a registered nurse to perform utilization review of inpatient, outpatient, and post-acute services. The role involves determining medical necessity, documenting decisions, and coordinating with the Medical Director and care management teams to ensure appropriate care across the health care continuum.

Responsibilities include data entry, interdepartmental communication, and ongoing participation in education initiatives.