Utilization Management Clinical RN
About The Position
We are searching for a Utilization Management Clinical RN. Someone who will provide precertification of inpatient hospitalizations and all outpatient procedures and services requiring authorization. To perform telephonic and/or concurrent review of inpatient hospitalizations and extended courses of outpatient treatment. This process includes clinical judgement, utilization management, application of product benefits, understanding of regulatory requirements, and verification of medical necessity utilizing nationally recognized criteria. In addition, discharge planning and provider education are major components of this process. Thank you've got what it takes?
Requirements
- Associate's Degree 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.
- RN - Lic-Registered Nurses Texas Board of Nursing or Nursing Licensure Compact required
- 3 years nursing experience required
Nice To Haves
- Bachelor's Degree Nursing preferred
Responsibilities
- Analyze submitted information including clinical assessments, treatment plan, regulatory guidelines, medical necessity, and accrediting standards for all requests
- Assess and process all denial determination
- Facilitates provider communication and education
- Liaisons with internal and external managed care staff members.
- Assess and refers potential case management cases.
- Ongoing assessment for quality indicators and concerns.
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What This Job Offers
Job Type
Full-time
Education Level
Associate degree
Number of Employees
5,001-10,000 employees
