Utilization Management RN: Care Coordination & Review

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 75,000 - 95,000; Full time

Job summary

CommunityCare HMO Inc. in Oklahoma seeks a Registered Nurse to perform utilization review and assess opportunities for coordination of care across the member population.

The role is part of the Utilization Management Team and requires collaboration with physicians and other providers to facilitate services across the health care continuum. The position emphasizes clinical review, documentation, and adherence to established criteria, with opportunities to contribute to Care Management programs

Qualifications

• Knowledge of managed care and related group benefit plans.
• Strong oral and written communication skills.
• Ability to reason logically and use good judgment.
• Knowledge of community-based resources.
• Excellent organizational and multitasking abilities.
• Proficiency in Microsoft applications.
• Strong time management and documentation skills.
• Health Care Sanctions background check completed.

Responsibilities

• Perform utilization review of outpatient, ancillary, inpatient and post-acute services.
• Determine medical necessity using clinical criteria.
• Document all review determinations and contact providers/members timely.
• Refer cases not meeting criteria to Medical Director.
• Identify quality issues and refer to Medical Management leadership.
• Identify potential Care Management opportunities.
• Collaborate with physicians and providers to coordinate care.
• Perform accurate data entry.
• Communicate information to staff as required.
• Participate in continuing education and cross-department collaboration.
• Perform other duties as assigned.

Skills

Managed care knowledge

Oral and written communication

Judgment and reasoning

Organizational skills

Microsoft Office

Time management and documentation

Team collaboration

Education

RN license in OK

BSN preferred

Job description

CommunityCare HMO Inc. in Oklahoma seeks a Registered Nurse to perform utilization review and assess opportunities for coordination of care across the member population.

The role is part of the Utilization Management Team and requires collaboration with physicians and other providers to facilitate services across the health care continuum. The position emphasizes clinical review, documentation, and adherence to established criteria, with opportunities to contribute to Care Management programs