Utilization Mgmt Clinical RN

Texas Children's Medical Center; Bellaire (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

Texas Children's Medical Center in Bellaire, TX seeks an experienced Utilization Management Clinical Registered Nurse to preauthorize inpatient and outpatient services and perform telephonic/concurrent reviews.

You will analyze requests against guidelines, determine medical necessity, and collaborate with medical directors, providers, and plans to ensure timely determinations and compliant communications.

Qualifications

• Diploma in nursing required or an Associate's degree in nursing accepted by the Texas Board of Nursing.
• RN licensure required by Texas Board of Nursing or Nursing Licensure Compact.
• 3 years of nursing experience required.

Responsibilities

• Precertify inpatient hospitalizations and outpatient procedures/services requiring authorization.
• Perform telephonic and/or concurrent review of hospitalizations and extended outpatient treatment.
• Analyze requests against clinical guidelines and regulatory requirements.
• Apply clinical decision making to assess acuity and appropriateness of treatments.
• Create a case summary evaluation when medical necessity criteria are not met and discuss with medical leadership.
• Research clinical guidelines and stay current with Medicaid/manual changes for coverage determinations.
• Ensure timely denial letters per regulatory requirements.
• Communicate decisions to providers and document rationale meeting accrediting guidelines.

Skills

Clinical decision making

Education

Diploma in nursing

Associate's degree in nursing

Bachelor's degree in nursing

Job description

We’re searching for a Utilization Management Clinical Registered Nurse, 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.
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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
• 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.

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