Utilization Management RN - Care Coordination & Review

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

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.