Utilization Management Clinical Registered Nurse

Texas Children's; United States; On-site; USD 85,000 - 105,000; Full time

Job summary

Texas Children's is seeking an Utilization Management Clinical RN to provide precertification for inpatient hospitalizations and all outpatient services requiring authorization, and to perform telephonic and concurrent review of inpatient stays.

You will analyze requests against guidelines, determine medical necessity, and prepare case summaries for review with the medical director. Respiratory fit testing is part of safety compliance for successful candidates.

Qualifications

• Diploma in nursing or Associates degree accepted by the Texas Board of Nursing for RN licensure.
• Bachelor's degree in nursing preferred.
• RN license in Texas or Nursing Licensure Compact required.

Responsibilities

• Analyze requests and identify applicable guidelines and regulatory requirements.
• Assess clinical acuity and appropriateness of suggested treatment/services.
• Create case summaries for requests failing medical necessity and discuss with medical director.
• Ensure timeliness of denial letters within regulations.
• Create communication pieces to providers describing the decision-making rationale and notify providers in writing.
• Collaborate with health plan disciplines to meet goals and objectives.
• Screen and refer potential members to case management and evaluation for programs or coverage.
• Identify potential quality of care issues and/or fraud and abuse and refer appropriately.

Skills

Clinical decision-making

Precertification

Telephonic review

Regulatory compliance

Education

Diploma in nursing

Associates degree in nursing

Bachelor's degree in nursing

Job description

At our company, our mission starts with our people. Guided by our HEART values-Humility, Excellence, Accountability, Respect, and Trust-we strive to create a workplace where teammates feel valued, supported, and empowered to do their best work every day.

As a Utilization Management Clinical RN, you'll provide precertification of inpatient hospitalizations and all outpatient procedures and services requiring authorization, and perform telephonic and/or concurrent review of inpatient hospitalizations and extended courses of outpatient treatment.

Job Duties & 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
• 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.

Skills & 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