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.
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 Utilization Management Clinical LVN -- someone who works well in a fast-paced setting. In this position, you will provide precertification of inpatient hospitalizations and outpatient procedures and services requiring authorization. This process includes clinical judgment, utilization management application, verification of benefits, understanding of regulatory requirements, and medical necessity decisions utilizing nationally recognized criteria.
Think you’ve got what it takes?
Being fully vaccinated against COVID-19, including any booster dose(s) of the COVID-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees at Texas Children’s unless approved for a medical or religious exemption.
- Required H.S. Diploma or GED
- Required LVN - Lic-Licensed Vocational Nurses by the State of Texas
- Required 1-year managed care expertise and/or Utilization Management experience and 2 years’ experience working as an LVN
- Assess the treatment plan, clinical information, and medical necessity of all requested services. Utilizes established criteria to appropriately certify requested services within the established timeframe required. Consults with providers regarding the patient’s history and current care needs on an ongoing basis. Performs inpatient/outpatient preauthorization review and concurrent review as required by departmental needs. Provides/initiates discharge planning options within the network to providers and participates in coordinating the continuum of care.
- Facilitates provider communication and education. Notifies providers of approved services through written correspondence. Documents all activities and interactions in authorization systems. 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 to attain reasonable accessibility to promote quality of service and quality of care.
- Liaisons with payers and managed care staff members. Collaborates with all disciplines within the health plan to meet goals and objectives. Expeditiously communicates essential information between providers and HMOs to facilitate claims payment.
- Assess and refer potential case management cases. Screens and identifies potential members for referral to the TCHP case management department, meeting criteria for case management per the policy and procedure. Refers to potential members and collaborates with the case management team concerning medical history and current services being provided.
- Ongoing assessment for quality indicators and concerns. Identifies potential quality of care issues, tracks into an electronic system, and refers to appropriate QM staff. Works closely with UM Analyst to expedite appeals and complaint process by coordination of concurrent activity with policy and procedure requirements when applicable.
- Assess and process all denial determinations after the medical director review. Ensures the timeliness of all denial letters within regulatory requirements. Reviews all denial letters for appropriate regulatory verbiage, the accuracy of the individual contracted responsibility, and adherence to applicable policy and procedure about the denial letter process.
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