Utilization Management Clinical RN

We are searching for a Utilization Management Clinical RN.  Someone who will provide precertification of inpatient hospitalizations and all outpatient procedures and services requiring authorization. To perform telephonic and/or concurrent review of inpatient hospitalizations and extended courses of outpatient treatment. This process includes clinical judgement, utilization management, application of product benefits, understanding of regulatory requirements, and verification of medical necessity utilizing nationally recognized criteria. In addition, discharge planning and provider education are major components of this process.

 

Thank you've got what it takes?

 

Qualifications:

• Associate's Degree Nursing or an associate’s degree in a related field accepted by the Texas Board of Nursing for the purposes of obtaining and maintaining an RN license required.
• Bachelor's Degree Nursing preferred
• RN - Lic-Registered Nurses Texas Board of Nursing or Nursing Licensure Compact required
• 3 years nursing experience required

Responsibilities:

• Analyze submitted information including clinical assessments, treatment plan, regulatory guidelines, medical necessity, and accrediting standards for all requests
• Assess and process all denial determination
• Facilitates provider communication and education
• Liaisons with internal and external managed care staff members.
• Assess and refers potential case management cases.
• Ongoing assessment for quality indicators and concerns.

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.
To join our community of 15,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.
Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.