Utilization Management Clinical RN: Review & Coordination

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

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.