Utilization Management Clinical Registered Nurse (Rn) - Clinic

Utilization Management Clinical Registered Nurse (RN)

Job Summary We are searching for a Utilization Management Clinical RN -- someone who works well in a fast-paced setting. In this position, you will provide precertification of inpatient hospitalizations and all outpatient procedures and services requiring authorization. This role performs 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. Think you've got what it takes? Responsibilities * Analyze submitted information including clinical assessments, treatment plan, regulatory guidelines, medical necessity, and accrediting standards for all requests * 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 * Documents due process, attempts to gain adequate clinical information to analyze for decision, reviews all denial letters for appropriate regulatory verbiage, accuracy of the member plan type and adherence to applicable policy and procedure with regards to the denial letter process * 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 * Creates recommendation of direction for care planning based on projected course of treatment and prognosis analysis * Creates a cost benefit analysis in situations where coverage outside of benefit s needs to be evaluated on due to unique member situation and delivers that to medical director/designee * Works closely with UM Analyst staff to expedite appeals and complaint process by coordination of concurrent activity with policy and procedure requirements Qualifications Being fully vaccinated against COVID-19, including any booster dose(s) of the COVID-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees at Texas Children's, unless approved for a medical or religious exemption * Diploma in or associate's 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 * Bachelor's degree in Nursing preferred * RN license from the Texas Board of Nursing or Nursing Licensure Compact required * 3 years nursing experience required * Experience with Utilization Management or Case Management preferred Company Profile Founded in 1996, Texas Children's Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area. To join our community of 14,000 dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org. At Texas Children's Hospital, diversity, equity, and inclusion are at the core of our values and mission for the women and children that we serve. We are committed to providing a diverse and inclusive work environment for all faculty, staff and learners throughout our organization. We believe that each member of our one amazing team provides enrichment that allows us to create a lasting legacy for future employees of this great organization. Texas Children's is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved."