Utilization Mgmt Clinical RN

Position: Utilization Mgmt Clinical RN

Job ID: 149130

Location: US-TX-Houston

Department: Utilization Management

Talent Area: Registered Nurse

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p

About Texas Children's Hospital

Since 1954, Texas Children’s has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children’s hospital in Texas, and among the top in the nation by U.S.News & World Report as well as recognition from Houston Business Journal as one of this city’s Best Places to Work for ten consecutive years. Texas Children’s comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Center for pediatric research; Texas Children’s Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children’s Hospital West Campus, a community hospital in suburban West Houston; and Texas Children’s Hospital The Woodlands, a second community hospital opening in 2017. We have also created the nation’s first HMO for children, established the largest pediatric primary care network in the country and a global health program that is channeling care to children and women all over the world. Texas Children’s Hospital is also academically affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation. 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 to provide precertification of inpatient hospitalizations , all outpatient procedures and services requiring authorization; to perform telephonic and/or concurrent review of inpatient hospitalizations and extended courses of outpatient treatment.


Required Competencies:

  • Clinical judgement, professionalism
  • Health plan utilization management,
  • Electronically proficient, average typing abilities
  • Understanding of regulatory requirements, and verification of medical necessity utilizing nationally recognized criteria.
  • Comfortable working an exempt , week day schedule with occasional late afternoons


Responsibilities :

Specific Duties

  • Prep cases for Medical Director review when indicated
  • 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, maintains currency of clinical guideline elements.
  • Evaluates discharge planning risk and facilitates creation of discharge plan within the network to providers to support continuity of care matching medical necessity and appropriateness of service.
  • Meets regulatory timelines for assessment of condition, decision making, and communication.
  • Serves as reference for intake staff on questions of coverage or necessity of transaction.
  • Documents all provider communication/education regarding status of authorization in the authorization system.
  • Promotes provider satisfaction with ongoing education regarding managed care and the process and procedure of the

authorization requirements.

  • Acts as liaison between providers and facilities, this includes telephone conversations, provider meetings, or going to the provider site to conduct review to attain reasonable accessibility to promote quality of service and quality of care.
  • Ensures the timeliness of all denial letters within the regulations mandated.
  • Acts as liaison between providers and facilities, this includes telephone conversations, provider meetings, or going to the provider site to conduct review to attain reasonable accessibility to promote quality of service and quality of care.


Please note, this is an in office position during the training period of 6 months.  Upon meeting department set metrics for a determined period of time, the possibility to work from home can be considered.


Knowledge Base Required and Preferred Skills

  • RN Degree 
  • 3 years Nursing Experience
  • Highly motivated and able to work independently.
  • Must be a team player.
  • Knowledge of pediatrics a plus. (including critical care and/or medical surgical)
  • Experience in managed care or utilization management preferred.
  • Excellent verbal, written and computer skills
  • Knowledge of NCQA standards is a plus.


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