Medical Management - Utilization Management RN 145-2026

CommunityCare•Tulsa, OK

About The Position

Responsible for clinical review of utilization requests and assessment and implementation of potential coordination-of-care opportunities for overall membership, institutionalized populations, high-risk members, and other members identified as having at-risk or high-utilization needs. Serves as an active team member of the Utilization Management Team.

Requirements

Graduate from an accredited School of Nursing.
Hold a current, active, unrestricted license to practice as a Registered Nurse in the State of Oklahoma.
Knowledge of managed care and associated group benefit plans.
Strong oral and written communication skills.
Ability to reason logically and use good judgment when interpreting materials or situations.
Knowledge of community-based resources.
Excellent organizational skills and ability to perform multiple tasks.
Proficiency in Microsoft applications.
Excellent time management and documentation skills.
Successful completion of a Health Care Sanctions background check.

Nice To Haves

Three years of acute care experience preferred.
Two years of experience working with population health preferred.
Previous discharge planning or case management experience preferred.
Managed care experience is a plus.

Responsibilities

Perform utilization review of outpatient and ancillary services, as well as inpatient and post-acute services when indicated.
Determine medical necessity and appropriateness of services using clinical review criteria.
Accurately document review determinations and contact providers and members according to established timeframes.
Identify and refer cases that do not meet established clinical criteria to the Medical Director.
Identify and refer quality issues to Medical Management leadership.
Identify potential cases for Care Management programs.
Collaborate with physicians and other providers to facilitate services throughout the health care continuum.
Perform accurate data entry.
Communicate appropriate information to other staff members as necessary or required.
Participate in continuing education initiatives.
Collaborate with other departments as needed.
Perform other duties as assigned.