UM/ECM - RN Reviewer HP

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

19h • Onsite

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. 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.

Requirements

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

Nice To Haves

• BSN preferred

Responsibilities

• Coordinate and efficiently utilize health care resources for Cook Childrens 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, 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 are met for CCHP.

What This Job Offers

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