Registered Nurse-Utilization Management

 
Position: Registered Nurse-Utilization Management

Job ID: 149612

Location: US-TX-Bellaire

Department: Utilization Management

Talent Area: Registered Nurse

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8am-5pm

About Texas Children's Hospital

Texas Children’s Health Plan (TCHP) is the largest Texas Medicaid managed care organization, and is part of the Texas Children’s healthcare system. Founded in 1996, TCHP is the nation's first health maintenance organization (HMO) created just for children and pregnant women. Our plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area. Currently the Health Plan serves more than 450,000 members across three service areas (Harris, Jefferson, North East). Members of the plan receive care from our network of more than 4,000 primary care physicians, 8,000 specialists, and 110 hospitals. They can also receive care at The Center for Children and Women, a patient and family-centered medical home with two convenient locations for TCHP members who can have all their medical needs met in one place, receiving multiple services the same day. TCHP is a recognized leader at encouraging holistic care that empowers families to live healthier lives.   To join our community of 13,000 dedicated team members, visit www.texaschildrenspeople.org for career opportunities.   You can also learn more about our amazing culture at www.infinitepassion.org

Summary:

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’ll also 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. Additionally, you’ll discharge planning and provider education are major components of this process.

 

Think you’ve got what it takes?



Responsibilities :

  • Analyze submitted information including clinical assessments, treatment plan, regulatory guidelines, medical necessity, and accrediting standards for all requests
  • Analyzes unique situation of request, identifying appropriate guideline and regulatory requirements for each request
  • Assess and process all denial determination
  • Ensures the timeliness of all denial letters within the regulations mandated
  • Facilitates provider communication and education
  • 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
  • Liaisons with internal and external managed care staff members
  • Collaborates with all disciplines within the health plan to meet goals and objectives meeting with contracting and provider relations on routine basis
  • Assess and refers potential case management cases
  • Screens, identifies, and refers potential members to case management and evaluation for programs or coverage
  • Ongoing assessment for quality indicators and concerns
  • Identify potential quality of care issues, and/or fraud and abuse, and refers to appropriate department


Qualifications:

  • 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


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