Medical Management - Utilization Management RN 145-2011
RemoteUnited States
Job Summary
Conduct clinical review of outpatient, inpatient, and post-acute utilization requests to assess medical necessity and appropriateness of services. Implement coordination of care opportunities for high-risk members and institutionalized populations while accurately documenting determinations and contacting providers within established timeframes. Identify cases requiring referral to the Medical Director for quality issues or potential entry into Care Management programs. Collaborate with physicians and other departments to facilitate service provision throughout the health care continuum. Perform accurate data entry and participate in continuing education initiatives. Requires current Oklahoma RN license, three years of acute care experience, and proficiency in Microsoft applications.
Required Qualifications
- Knowledge of managed care and associated group benefit plans
- Possess strong oral and written communication skills
- Ability to reason logically and to use good judgment when interpreting materials or situations
- Knowledge of community- based resources
- Must have excellent organizational skills and be able to perform multiple tasks
- Proficient in Microsoft applications
- Excellent time management and documentation skills
- Successful completion of Health Care Sanctions background check
- Graduation from accredited School of Nursing
- Current, active, unrestrictive license to practice as a Registered Nurse in the State of Oklahoma
Desired Qualifications
- 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
Hiring someone like this?
Get your role in front of qualified candidates on Sorce.