Utilization Management Clinical Registered Nurse

Texas Children's Medical Center•Houston, TX

13d

About The Position

We’re searching for a Utilization Management Clinical RN, someone who works well in a fast-paced setting. In this position, you’ll be responsible for providing precertification of inpatient hospitalizations and all outpatient procedures and services requiring authorization, and performing telephonic and/or concurrent review of inpatient hospitalizations and extended courses of outpatient treatment. Think you’ve got what it takes?

Requirements

Diploma in nursing required or Associates degree in nursing or an associate’s degree in a related field accepted by the Texas Board of Nursing for the purposes of obtaining and maintaining an RN license required or Bachelor's degree in nursing preferred
RN - Lic-Registered Nurses by Texas Board of Nursing or Nursing Licensure Compact required
3 years of nursing experience required

Responsibilities

Analyzes unique situation of request, identifying appropriate guideline and regulatory requirements for each request
Applies clinical decision making to assessment of clinical acuity and appropriateness of suggested treatment/services
Creates a case summary evaluation for requests failing medical necessity criteria, and has collaborative discussion with the medical director or designee for review and disposition
Researches clinical guidelines for potential investigative service requests, researches weekly changes to Medicaid manual to assure coverage determinations, and maintains currency of clinical guideline elements
Ensures the timeliness of all denial letters within the regulations mandated
Creates communication pieces to providers, which meet accrediting and regulatory guidelines for clinical content and readability levels describing decision making rationale for service requests and notifies providers through written correspondence
Collaborates with all disciplines within the health plan to meet goals and objectives meeting with contracting and provider relations on routine basis
Screens, identifies, and refers potential members to case management and evaluation for programs or coverage
Identifies potential quality of care issues, and/or fraud and abuse, and refers to appropriate department
As part of our commitment to maintaining a safe and healthy workplace, all successful candidates will be required to undergo respiratory fit testing in compliance with occupational health and safety standards.