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.
KEY 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.
- 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.
- 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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