Medical Management - Patient Care Specialist 145-2031
Responsible for clinical review of services requiring medical authorization and documentation of decisions and clinical information. This role practices independent judgement using clinical knowledge prioritizing cases based upon medical necessity and regulatory guidelines. In addition, uses discretion with everyday confidentiality preserving patient cases.
- Reviews requests for services (inpatient, ancillary, and outpatient). Makes decisions according to guidelines and criteria or refers cases and documents in authorization system.
- Responsible for provider and member notifications related to decisions associated with organization determinations.
- Serves as a resource to Patient Care Coordinator to provide information relative to current techniques and departmental process according to appropriate assignment.
- Reports provider issues to identify network issues or access problems.
- Investigates escalated complaints and identifies and resolves associated authorization problems.
- Participates in employee audits to ensure quality measures and monitors workflow to improve operations and streamline process for appropriate network.
- Performs other duties as required.
- Ability to assess situation, consider alternatives and choose the appropriate course of action.
- Ability to reason logically and to use good judgment when interpreting materials or situations.
- Knowledge of managed care and associated group benefit plans.
- Proficient in Microsoft applications.
- Successful completion of Health Care Sanctions background check.
- Ability to organize time effectively and set priorities.
- Possess strong oral and written communication skills.
- Graduation from accredited School of Nursing.
- Current, active, unrestricted license to practice as Registered Nurse (RN) in the State of Oklahoma.
- At least three years of clinical nursing experience in an acute care setting.
CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin
- Pay Type Salary
- Tulsa, OK, USA