RN Reviewer, Health Plan/Utilization Mgmt.

Cook Children's Health Care System • Fort Worth, TX

4d • Onsite

About The Position

Responsible for the coordination and efficient utilization of health care resources for Cook Children's Health Plan (CCHP) members. Works with the Department Manager and Team Lead to assure the timely provision of quality care throughout the continuum of care. The Registered Nurse Utilization Management/Episodic Case Manager (UM/ECM - RN) Reviewer facilitates clinically appropriate and fiscally responsible care through communication with the providers and health plan medical directors. The UM/ECM - RN Reviewer assesses and identifies the members clinical information and determines, in conjunction with the Medical Director, medical necessity and appropriateness of requested services. Utilizes Medical Management Committee (MMC) approved clinical criteria to authorize requested services for the member. The UM/ECM - RN Reviewer communicates with providers of care/services to facilitate appropriate care transitions. The UM/ECM - RN Reviewer assures adherence to regulatory/contractually required timeliness standards for authorization request processing, associated communications and notice of adverse determinations are met for CCHP.

Requirements

• Associate degree of Nursing required
• RN with a minimum of five (5) years clinical experience.
• 2 years utilization management or case management experience required.
• Strong skills in oral and written communication
• Strong skills in critical thinking
• Strong skills in organization and time management
• Strong skills in customer service
• Current unrestricted Registered Nurse licensure in the State of Texas.

Nice To Haves

• BSN preferred

Responsibilities

• Coordination and efficient utilization of health care resources for Cook Children's Health Plan (CCHP) members.
• Facilitate clinically appropriate and fiscally responsible care through communication with providers and health plan medical directors.
• Assess and identify member's clinical information and determine medical necessity and appropriateness of requested services in conjunction with the Medical Director.
• Utilize Medical Management Committee (MMC) approved clinical criteria to authorize requested services.
• Communicate with providers of care/services to facilitate appropriate care transitions.
• Assure adherence to regulatory/contractually required timeliness standards for authorization request processing, associated communications, and notice of adverse determinations.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree