Utilization Management RN: Clinical Review & Care 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 RN Utilization Review Nurse to assess and implement care coordination opportunities for members with high utilization.

The role requires nursing licensure in Oklahoma and a nursing degree, with preference for acute care and population health experience. The nurse will collaborate with physicians and staff in the Utilization Management Team and ensure timely documentation of reviews.

Qualifications

• Must be a graduate of an accredited School of Nursing.
• Current, active RN license in Oklahoma.
• Prefer 3 years acute care experience and 2 years in population health.
• Managed care experience is a plus.

Responsibilities

• Performs utilization review of outpatient, ancillary, inpatient and post-acute services as indicated.
• Determines medical necessity and appropriateness using clinical criteria.
• Documents all review determinations and communicates with providers and members per timeframes.
• Identifies cases not meeting criteria and refers to Medical Director.
• Flag quality issues to Medical Management leadership.
• Identifies potential Care Management opportunities.
• Collaborates with physicians and providers to coordinate care across the health system.
• Communicates information to staff as required and participates in education.
• Partners with other departments as needed and performs other duties.

Skills

Managed care knowledge

Communication skills

Judgment and reasoning

Organizational skills

Time management

MS Office proficiency

Documentation skills

Education

Graduation from accredited School of Nursing

RN license in Oklahoma

Job description

CommunityCare, Inc. in Tulsa, OK is seeking a RN Utilization Review Nurse to assess and implement care coordination opportunities for members with high utilization.

The role requires nursing licensure in Oklahoma and a nursing degree, with preference for acute care and population health experience. The nurse will collaborate with physicians and staff in the Utilization Management Team and ensure timely documentation of reviews.