Medical Management - Utilization Management RN 145-2026
RemoteUnited States
United StatesRemoteFull TimeLicense Or CertificationMedium
Full TimeLicense Or CertificationMedium
Job Summary
Conduct clinical review of outpatient, inpatient, and post-acute utilization requests to determine medical necessity and appropriateness. Assess and implement coordination of care opportunities for high-risk members and institutionalized populations. Accurately document review determinations, contact providers and members within established timeframes, and refer cases to the Medical Director or leadership as required. Identify potential cases for Care Management programs and collaborate with physicians to facilitate services across the health care continuum. Perform accurate data entry and participate in continuing education initiatives.
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
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