RN Reviewer, Utilization Mgmt.

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

1d • Remote

About The Position

Responsible for the coordination and efficient utilization of health care resources for Cook Childrens 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. This role will mainly coordinate members needing Behavioral Health and outpatient procedures but must be willing to cross-train in different areas.

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
• Current unrestricted RN licensure in the State of Texas
• Strong organizational and time-management skills
• Ability to effectively prioritize multiple tasks
• Ability to work efficiently across a variety of electronic platforms and systems
• Exceptional oral and written communication skills
• Strong critical-thinking and problem-solving skills
• Responsive, customer-focused service delivery
• Ability to effectively manage diverse needs and priorities
• Ability to work in a fast-paced environment
• Ability to meet deadlines
• Must maintain primary residence within the state of Texas

Nice To Haves

• BSN preferred
• Critical Care experience preferred
• Discharge planning experience preferred
• Experience with Behavioral Health preferred

Responsibilities

• Coordinate the efficient utilization of health care resources for Cook Children's Health Plan (CCHP) members.
• Assure the timely provision of quality care throughout the continuum of care.
• Facilitate clinically appropriate and fiscally responsible care through communication with providers and health plan medical directors.
• Assess and identify members' clinical information.
• Determine, in conjunction with the Medical Director, the medical necessity and appropriateness of requested services.
• 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: Mid Level
• Education Level: Associate degree