Registered Nurse (RN) - Utilization Management - PCHP - PRN

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

Primary Purpose

Parkland Community Health Plan's (PCHP's) Utilization Management (UM) Clinician is responsible for processing authorization requests for members requiring physical and/or behavioral healthcare for outpatient and inpatient service. UM responsibilities include but are not limited to processing of prior and concurrent review authorizations, discharge planning and transitions of care. Oversees the application of clinical guidelines in determining appropriateness of requested and continued healthcare services. Ensures that all clinical decisions are completed according to evidence based best practice guidelines and meets regulatory requirements. Seeks Medical Director review of cases not meeting criteria and monitors time frames for decision making and notifications of decision.

Minimum Specifications 

Education

• Bachelor's degree in Nursing; or Master's Degree in Social Work or a related field required.
• If serving physical health populations, graduation from an accredited school of nursing is required. 

Experience

• 3+ years of acute clinical nursing or medical management experience required. If serving behavioral health populations, at least three 3+ years of clinical social work or behavioral health experience required.
• 3+ years of experience in Texas Medicaid, Medicaid, or a Medicaid managed care organization or health plan preferred. 
• 1+ year experience with the implementation of utilization management policies, procedures, and protocols for physical health and/or behavioral health services and knowledge of utilization management and case management principles is preferred. 
• Experience managing pediatric population with complex PH/BH conditions preferred. 
• Experience in Texas Medicaid and NCQA is preferred. 

Certification/Registration/Licensure

• If primarily serving members with physical health needs, current and unrestricted licensure as a RN in the State of Texas required.
• If primarily serving members with behavioral health needs, must have and maintain an unrestricted license such as a RN, LPC, LMFT, or LCSW in the State of Texas. 

Skills or Special Abilities

• Knowledge of community resources, local service systems including indigent physical health and/or behavioral health systems.
• Knowledge of utilization management and case management principles.
• Understanding of utilization management principles, objectives, standards and methods, and of program policies and procedures.
• For those reviewing BH authorizations, demonstrate knowledge and utilization of evidence-based practices relevant to population served (persons who have experienced trauma, members with substance use disorder, members with serious mental illness or serious emotional disturbance).
• Competency in prior and concurrent review authorization functions including application of criteria and timelines.
• Demonstrated ability to analyze clinical information and accurately apply clinical criteria.
• Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms. Proven history of effective communication and counseling skills
• Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization.
• Excellent analytical and problem-solving skills.
• Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.
• Ability to write clearly and succinctly with a high level of attention to detail.
• Proficient computer and Microsoft Office skills. Ability to learn new software programs. 
• Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual. - Familiar with InterQual and Texas Medicaid Provider Procedures Manual and utilization guidelines.
• Solid understanding of managed care and medical terminology.
• Knowledge of and competence in use of UM software.
• Foster strong, positive, and effective working relationships with inter-system and intra-system team members, encouraging and supporting interaction among various team members across organizational lines.

Responsibilities

• Care Coordination and Clinical Review Performs clinical utilization reviews of pre-authorization, concurrent and retrospective requests per clinical information submitted by providers using clinical criteria for medical necessity and appropriateness of care.
• Approves services or forwards requests to the appropriate medical director for further review, as appropriate. Performs utilization management functions competently and adheres to the guidelines for authorization turn-around times.
• Reviews clinical service requests from members or providers using evidence based clinical guidelines, analyzes clinical information and correctly applies clinical criteria. Requests additional information from members or providers in a timely manner and makes referrals to other clinical programs as needed.
• Identifies members that are high risk or who have conditions that may need service coordination or disease management and facilitates appropriate referrals. Works collaboratively with provider network and health services team to coordinate member care.
• Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Answers utilization management directed telephone calls, managing them in a professional and competent manner.
• Conducts ongoing availability, monitoring, and oversight of non-clinical staff activities. Uses effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to assure appropriate levels of care are received by members. Identifies and utilizes appropriate alternative and non-traditional available resources in managing cases.
• Documentation Provides accurate and complete documentation along with an explanation of the rationale that was used to approve requests. Documents and maintains clinical information in health management systems ensuring all pertinent information is entered in a timely manner and in accordance with department guidelines.
• Performs medical necessity documentation to expedite approvals and ensure that appropriate follow up is performed.
• Regulatory Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.
• Professional Accountability Promotes and supports a culturally welcoming and inclusive work environment. Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values. Adheres to organizational policies, procedures, and guidelines.
• Completes assigned training, self-appraisal, and annual health requirements timely. Adheres to hybrid work schedule requirements. Attends required meetings and town halls.
• Recognizes and communicates ethical and legal concerns through the established channels of communication. Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information.
• Maintains confidentiality at all times. Performs other work as requested that is reasonably related to the employee's position, qualifications, and competencies.

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. As part of our commitment to our patients and employees’ wellness, Parkland Health is a tobacco and smoke-free campus.