UM/ECM - RN Reviewer HP

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

1d • Onsite

About The Position

The Registered Nurse Utilization Management/Episodic Case Manager (UM/ECM - RN) Reviewer is responsible for the coordination and efficient utilization of health care resources for Cook Children's Health Plan (CCHP) members. This role works with the Department Manager and Team Lead to ensure the timely provision of quality care throughout the continuum of care. The UM/ECM - RN Reviewer facilitates clinically appropriate and fiscally responsible care through communication with providers and health plan medical directors. Key duties include assessing and identifying members' clinical information, determining medical necessity and appropriateness of requested services in conjunction with the Medical Director, and utilizing Medical Management Committee (MMC) approved clinical criteria to authorize services. The reviewer also communicates with providers to facilitate appropriate care transitions and ensures adherence to regulatory and contractual timeliness standards for authorization request processing, associated communications, and notice of adverse determinations for CCHP.

Requirements

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

Nice To Haves

• BSN preferred

Responsibilities

• Coordinate and efficiently utilize health care resources for Cook Children's Health Plan (CCHP) members.
• Work with the Department Manager and Team Lead to 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 for the member.
• 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
• Number of Employees: 501-1,000 employees