Utilization Management RN — Care Review & Coordination

CommunityCare, Inc.; Tulsa, Northern (OK, KY); Hybrid; USD 70,000 - 90,000; Full time

Job summary

CommunityCare, Inc. in Tulsa, OK is seeking a Registered Nurse to perform clinical review of utilization requests and implement care coordination opportunities for at‑risk members.

You will be part of the Utilization Management Team, collaborating with physicians and other providers to ensure medical necessity and appropriate care across the health care continuum. This role requires Oklahoma RN license and 3 years acute care experience; managed care knowledge and strong documentation skills are

Qualifications

• Bachelor of Science in Nursing from an accredited program.
• Active, unrestrictive Oklahoma RN license.
• Three years acute care experience preferred.
• Two years population health experience preferred.
• Managed care knowledge and strong documentation skills.

Responsibilities

• Performs utilization review of outpatient and inpatient services.
• Determines medical necessity using clinical criteria.
• Documents review determinations and communicates with providers/members.
• Refers cases not meeting criteria to Medical Director.
• Identifies quality issues and refers to Medical Management leadership.
• Collaborates with physicians to coordinate care across the continuum.
• Participates in continuing education and cross‑department collaboration.
• Performs other duties as assigned.

Skills

Managed care knowledge

Communication skills

Time management

Clinical reasoning

Education

Bachelor of Science in Nursing

Oklahoma RN license

Tools

Microsoft Office

Job description

CommunityCare, Inc. in Tulsa, OK is seeking a Registered Nurse to perform clinical review of utilization requests and implement care coordination opportunities for at‑risk members.

You will be part of the Utilization Management Team, collaborating with physicians and other providers to ensure medical necessity and appropriate care across the health care continuum. This role requires Oklahoma RN license and 3 years acute care experience; managed care knowledge and strong documentation skills are