Job Description

This is a great opportunity for a UR professional who is looking for a new challenge. The UR Nurse Manager will work as a member of a single employer health plan in a non-traditional care management setting. A publicly traded, Tulsa headquartered energy company is looking to add a UR Nurse Manager to its health care team.

The UR Nurse Manager will provide plan participants with appropriate and comprehensive utilization of health care services and benefits as designated. This requires an experienced RN with a diverse clinical background as well as experience within the managed care industry and specifically in the self-funded arena. Will work with providers, hospitals and participants to achieve optimal outcomes and appropriate use of services and benefits. This position is performed on-site at the Tulsa office location. Remote or hybrid is NOT an option.

This position reports to the Health Plan General Manager and requires:

SUMMARY: The Utilization Review Nurse Manager manages daily activities within the Health Plan's Utilization Management function. Promotes the use of health care services or interventions that are necessary and appropriate, medically effective, and allowable under the Plan. Establishes and tracks performance against measures of productivity, efficiency, and effectiveness. Oversees the work of clinical staff that evaluates patient needs and determines medical necessity of care plans or accuracy of charges. Collaborates with internal Care Team Members and external care providers to develop care plans that balance care quality with care cost, ensuring appropriate usage of resources. Prepares reports summarizing utilization trends and identifies opportunities for utilization/cost reduction.

ESSENTIAL DUTIES AND RESPONSIBILITIES: The items listed below detail some of the assigned duties and responsibilities for this position. This is not meant to be an all-inclusive list, and management reserves the right to change these duties at any time.

• Leads and directs the work of other employees including UR Nurse and UR Coordinator.
• Serves as a member of the Health Plan Leadership Team
• Oversees pre-certification (pre-authorization) of outpatient services utilizing Milliman Care Guidelines (MCG), SPD, and/or Plan medical policies.
• Conducts Inpatient admission reviews with determination of level of care and length of stay based on MCG criteria.
• Performs concurrent reviews with the determination of the level of care and extended length of stay based on the severity of illness and the intensity of service utilizing MCG criteria.
• Collaborates with Medical Director, Health Plan General Manager, Care Coordination Manager and other professional staff to ensure appropriate treatment plans and delivery of authorized services.
• Serves as a member of Appeal Committee and presents necessary information to facilitate reviews and determinations.
• Assessment of the clinical status and prognosis to develop an appropriate discharge plan to meet the individual's health care needs.
• Submits appropriate referrals to the Care Coordination Team based on the participants clinical status and care needs.
• Researches and identifies services, resources, providers, and facilities that could best serve participants in a timely and cost-effective manner to obtain optimum value for the participant and Plan.
• Maintains participant's privacy, confidentiality and safety in compliance with HIPPA regulations as well as acting as an advocate for the participant.
• Maintains adherence to ethical, legal and ERISA regulatory standards.
• Assures accuracy in clinical documentation within medical management system.

QUALIFICATIONS: The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION AND EXPERIENCE

• Requires a graduate of an accredited school of nursing and must hold current and unrestricted Oklahoma state license or Nursing Licensure Compact (NLC) as a RN, LVN, or LPN.
• Prior supervisory experience in a similar capacity.
• Professional background in a broad range of clinical nursing and patient assessment areas (ICU, NICU, Medical/Surgical, Behavioral Health, and/or Substance Abuse).
• Prior experience in utilization management or case management, preferably in the managed care environment.
• Knowledgeable of medical terminology, reasonable and necessary treatment plans, delivery quality health care services and cost containment practices.
• Experience using Milliman Care Guidelines strongly preferred.
• Familiarity with ICD 11 and CPT codes a plus.

COMMUNICATION SKILLS

• Proficiency in maintaining good rapport with physicians, health care facilities, participants, and providers.
• Must have strong communication and interpersonal skills to be able to use professionalism when speaking to our members or to their providers or other UM nurses at hospitals on the telephone or in person to ensure proper information is relayed and processes are followed.
• Answer questions about pre-authorization criterion, provide current status of authorizations or denials, and explain pre-authorization and appeal process when asked.

OTHER SKILLS

• Knowledge of managed care in a self-funded employer population will be beneficial.
• Assertiveness, self-motivation, and a sense of responsibility are a must.

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