Utilization Mgmt Clinical RN

Position: Utilization Mgmt Clinical RN

Job ID: 141975

Department: Utilization Management

Talent Area: Registered Nurse

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p

About Texas Children's Hospital

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 13,000 dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.


We are searching for a Utilization Management Clinical RN – someone who works well in a fast-paced hospital setting. In this position, you’ll provide precertification of inpatient hospitalizations and all outpatient procedures and services requiring authorization. You will 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.


Think you’ve got what it takes?


Responsibilities :

Job Duties & Responsibilities 

    • Analyze submitted information, including clinical assessments, treatment plans, regulatory guidelines, medical necessities, and accrediting standards for all requests 
    • Assess and process all denial determination 
    • Facilitate provider communication and education 
    • Liaise with internal and external managed care staff members 
    • Assess and refer potential case management cases
    • Provide ongoing assessment for quality indicators and concerns



Skills & Requirements


    • A Bachelor of Science in Nursing, Associate Degree in Nursing, or Diploma in Nursing (Bachelor of Science in Nursing is preferred) 
    • Registered Nurse (RN) license without restriction by the Texas State Board of Nursing 
    • Three (3) years of nursing experience  
    • At least 2-3 years’ prior experience in utilization management or case management 
    • Orientation 3-4 months in the office before transition home; before transitioning home, must demonstrate ability to process at a minimum 15 cases a day  
    • Prior experience working with a Medicaid MCO is preferable 
    • Excellent verbal and written skills as well as computer skills 
    • Highly motivated and able to work independently  
    • Must be a team player 
    • Knowledge of pediatrics is a plus


  • Experience in managed care or utilization management preferred




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