RN Reviewer, Utilization Mgmt.

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

23h • 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. The RN Reviewer/Utilization Management will coordinate the efficient utilization of health care resources for Cook Children's Health Plan (CCHP) members. This role will mainly coordinate members needing Behavioral Health and outpatient procedures but must be willing to cross-train in different areas. The RN will work closely with the Department Manager and Team Lead to assure the timely provision of quality care throughout the continuum of care. The RN Reviewer facilitates clinically appropriate and fiscally responsible care through communication with the providers and health plan medical directors. Will assess and identify the members clinical information and determine, 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
• Current unrestricted RN licensure in the State of Texas
• Strong organizational and time-management skills, with the ability to effectively prioritize multiple tasks and work efficiently across a variety of electronic platforms and systems.
• Demonstrates exceptional oral and written communication, applies strong critical-thinking and problem-solving skills, and delivers responsive, customer-focused service while effectively managing diverse needs and priorities.
• Ability to work in fast-paced environment and meet deadlines.
• Must maintain primary residence within the state of Texas.

Nice To Haves

• BSN preferred
• Critical Care and discharge planning experience preferred
• Experience with Behavioral Health preferred
• Willing to cross-train in different areas

Responsibilities

• Coordinate the 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 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