Medical Management - Utilization Management RN 140-2015

About the Role

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 with at-risk or high-utilization needs. Functions as an active team member of the Utilization Management Team.

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.

Requirements

• 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.
• Proficient in Microsoft applications.
• Excellent time management and documentation skills.
• Successful completion of Health Care Sanctions background check.

Qualifications

• Graduation from accredited School of Nursing.
• Current, active, unrestrictive license to practice as a Registered Nurse in the State of Oklahoma.
• 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 a plus.