Utilization Management RN: Care Coordination Specialist

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

Job summary

CommunityCare HMO Inc. seeks a Registered Nurse to perform clinical review of utilization requests and assess and implement potential coordination of care opportunities for overall membership, including high-risk and at-risk populations.

The role is part of the Utilization Management Team and requires collaboration with physicians and other providers across the care continuum. Responsibilities include determining medical necessity, documenting determinations, referring cases to Medical Director,

Qualifications

• Nurse with graduation from accredited School of Nursing.
• Current, active RN license in Oklahoma.
• Three years acute care experience preferred.
• Two years population health experience preferred.
• Discharge planning or case management experience preferred.
• Managed care experience a plus.

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

Oral and written communication

Judgment / reasoning

Community resources knowledge

Organizational skills

Time management

Documentation skills

Education

Graduation from accredited School of Nursing

Current, active RN license in Oklahoma

Tools

Microsoft applications

Job description

CommunityCare HMO Inc. seeks a Registered Nurse to perform clinical review of utilization requests and assess and implement potential coordination of care opportunities for overall membership, including high-risk and at-risk populations.

The role is part of the Utilization Management Team and requires collaboration with physicians and other providers across the care continuum. Responsibilities include determining medical necessity, documenting determinations, referring cases to Medical Director,