Utilization Management RN: Care Coordination & Review

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 65,000 - 90,000; Full time

Job summary

CommunityCare HMO Inc. seeks a Registered Nurse to perform utilization review of services and assess coordination of care for members, including high-risk populations and populations with elevated utilization.

The role involves documenting review determinations, referring non-qualifying cases to the Medical Director, and collaborating with providers to ensure care across the health care continuum. Health care sanctions background check required.

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 multitask.
• 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 within established timeframes.
• Identifies and 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 services across the health care continuum.
• Performs accurate data entry.
• Communicates information to staff 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

Background check

Education

R.N. license in Oklahoma

Nursing degree from accredited school

Tools

Microsoft Office

Job description

CommunityCare HMO Inc. seeks a Registered Nurse to perform utilization review of services and assess coordination of care for members, including high-risk populations and populations with elevated utilization.

The role involves documenting review determinations, referring non-qualifying cases to the Medical Director, and collaborating with providers to ensure care across the health care continuum. Health care sanctions background check required.