Utilization Management Clinical Registered Nurse The Health Plan - Remote

 
Position: Utilization Management Clinical Registered Nurse The Health Plan - Remote

Job ID: 21599

Location: --

Department: Texas Children's Hospital

Shift: 9a - 6p

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.



Summary:

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

Qualifications:

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

  • Diploma in or associate’s degree in Nursing, or an associate’s degree in a related field accepted by the Texas Board of Nursing for the purposes of obtaining and maintaining an RN license
  • Bachelor’s degree in Nursing preferred
  • RN license from the Texas Board of Nursing or Nursing Licensure Compact required
  • 3 years nursing experience required
  • Experience with Utilization Management or Case Management preferred 

 

Responsibilities:

  • Analyze submitted information including clinical assessments, treatment plan, regulatory guidelines, medical necessity, and accrediting standards for all requests
  • 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
  • Documents due process, attempts to gain adequate clinical information to analyze for decision, reviews all denial letters for appropriate regulatory verbiage, accuracy of the member plan type and adherence to applicable policy and procedure with regards to the denial letter process
  • 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
  • Collaborates with all disciplines within the health plan to meet goals and objectives meeting with contracting and provider relations on routine basis
  • Creates recommendation of direction for care planning based on projected course of treatment and prognosis analysis
  • Creates a cost benefit analysis in situations where coverage outside of benefit s needs to be evaluated on due to unique member situation and delivers that to medical director/designee
  • Works closely with UM Analyst staff to expedite appeals and complaint process by coordination of concurrent activity with policy and procedure requirements


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