Utilization Review Manager - Home Care jobs in Oklahoma

Description:

Utilization Review Nurse perform integrated case management (CM) and disease management (UM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members’ care including clinical nurses and treating physicians. Care Managers determine, develop and implement a plan of care based on accurate and comprehensive assessment of the member’s needs. Care Managers apply detailed knowledge of established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case.

Responsibilities:

• Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the member’s needs.

• Applies detailed knowledge of FEP PPO established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case.

• Works with complex cases, promotes the delivery of quality; cost-effective health care services based on medical necessity and contractual benefits.

• Provides guidance to the provider network via telephone triage.

• Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care via phone/ computer work.

• Makes referrals to Quality Management, Catastrophic Case Management and Appeals and Grievance Department via computer and virtual meetings.

• Screen enrollees for initiatives and programs including Case Management and Disease Management
• Use judgment in selecting appropriate guidelines
• Apply general policies and procedures
• Interface with patients, doctors, and other nurses regarding the status of patient care
• Suggest changes to patient care methods or facilities

Skills:

Acute care, acute, nurse, clinical, healthcare, Case management, Utilization management, Utilization review, Insurance

Top Skills Details:

Acute care, acute, nurse, clinical, healthcare, Case management

Additional Skills & Qualifications:

• Bachelor’ s of Science in Nursing or advanced degree preferred. • Active Oklahoma RN license required. • Case Manager, Discharge Planner, UR experience. • Utilization review experience in a facility

Experience Level:

Intermediate Level

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