Utilization Mgmt Clinical RN

Position: Utilization Mgmt Clinical RN

Job ID: 157371

Location: US-TX-Bellaire

Department: UM Initial Authorizations

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 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.   Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.


We are searching for a Clinical Registered Nurse (RN) to work in our Utilization Management Department with The Health Plan.   In this position, you’ll provide precertification for inpatient hospitalizations and all outpatient procedures and services requiring authorizations. 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. Additionally, 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


  • A Bachelor of Science in Nursing, Associate Degree in Nursing, or Diploma in Nursing (Bachelor of Science in Nursing is preferred)
  • Current licensure with the Board of Nursing for the State of Texas or Nurse Licensure Compact and BLS certification are required
  • Three (3) years of nursing experience
  • Managed Care experience as a Nurse Reviewer is strongly preferred

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