Utilization Management RN — Care Coordination & Review

CommunityCare, Inc.; Tulsa (OK); On-site; USD 70,000 - 90,000; Full time

Job summary

CommunityCare, Inc. seeks a highly organized Registered Nurse to lead utilization review and coordinate care for at-risk members in Oklahoma. The role focuses on evaluating outpatient, inpatient, and post-acute services and ensuring medical necessity per criteria.

With collaboration across physicians and care teams, you will document determinations, identify cases for Care Management, and participate in ongoing education to improve member outcomes. Acute care experience preferred.

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, ancillary, 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 timely.
• Identifies and refers cases that do not meet 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 information to staff; participates in continuing education initiatives.
• Collaborates with other departments; performs other duties as assigned.

Skills

Managed care knowledge

Communication skills

Judgment

Community resources knowledge

Organizational skills

Microsoft Office

Time management

Documentation skills

Education

Nursing degree

Registered Nurse license in OK

Tools

Microsoft Office

Job description

CommunityCare, Inc. seeks a highly organized Registered Nurse to lead utilization review and coordinate care for at-risk members in Oklahoma. The role focuses on evaluating outpatient, inpatient, and post-acute services and ensuring medical necessity per criteria.

With collaboration across physicians and care teams, you will document determinations, identify cases for Care Management, and participate in ongoing education to improve member outcomes. Acute care experience preferred.