Utilization Management RN – Care Coordination & Review

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 75,000 - 100,000; Full time

Job summary

CommunityCare is seeking a Registered Nurse to perform utilization review and coordinate care for members with high utilization risks. The role works as part of the Utilization Management Team to ensure medical necessity and quality across the care continuum.

The ideal candidate has an Oklahoma RN license, 3+ years acute care experience, and exposure to population health. Strong documentation and collaboration skills are essential for success.

Qualifications

• Must be a graduate of an accredited School of Nursing.
• Current, active Oklahoma RN license.
• Three years acute care experience preferred.
• Two years population health experience preferred.
• Managed care experience a plus.
• Strong communication and organizational skills.

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

Organization skills

Microsoft Office

Time management

Documentation skills

Education

RN license in Oklahoma

Tools

Microsoft Office

Job description

CommunityCare is seeking a Registered Nurse to perform utilization review and coordinate care for members with high utilization risks. The role works as part of the Utilization Management Team to ensure medical necessity and quality across the care continuum.

The ideal candidate has an Oklahoma RN license, 3+ years acute care experience, and exposure to population health. Strong documentation and collaboration skills are essential for success.