Utilization Management Clinical Registered Nurse

Job Description

We’re searching for a Utilization Management Clinical RN, someone who works well in a fast-paced setting. In this position, you’ll be responsible for providing precertification of inpatient hospitalizations and all outpatient procedures and services requiring authorization and performing telephonic and/or concurrent review of inpatient hospitalizations and extended courses of outpatient treatment.

Think you’ve got what it takes?

Job Duties & Responsibilities

• Analyzes unique situation of request, identifying appropriate guideline and regulatory requirements for each request
• Applies clinical decision making to assessment of clinical acuity and appropriateness of suggested treatment/services
• Creates a case summary evaluation for requests failing medical necessity criteria, and has collaborative discussion with the medical director or designee for review and disposition
• Researches clinical guidelines for potential investigative service requests, researches weekly changes to Medicaid manual to assure coverage determinations, and maintains currency of clinical guideline elements
• Ensures the timeliness of all denial letters within the regulations mandated
• Creates communication pieces to providers, which meet accrediting and regulatory guidelines for clinical content and readability levels describing decision making rationale for service requests and notifies providers through written correspondence
• Collaborates with all disciplines within the health plan to meet goals and objectives meeting with contracting and provider relations on routine basis
• Screens, identifies, and refers potential members to case management and evaluation for programs or coverage
• Identifies potential quality of care issues, and/or fraud and abuse, and refers to appropriate department
  
  
  

As part of our commitment to maintaining a safe and healthy workplace, all successful candidates will be required to undergo respiratory fit testing in compliance with occupational health and safety standards.

Skills & Requirements

• Diploma in nursing required or
• Associates degree in 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 or
• Bachelor's degree in nursing preferred
• RN - Lic-Registered Nurses by Texas Board of Nursing or Nursing Licensure Compact required
• 3 years of nursing experience required
  
  
  

About Us

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.