Utilization Management Denial Coordinator Licensed Vocational Nurse - LVN

 
Position: Utilization Management Denial Coordinator Licensed Vocational Nurse - LVN

Job ID: 164499

Location: US-TX-Houston

Department: UM DENIAL AND APPEAL

Talent Area: LVN

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 9a - 6p

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. At Texas Children’s Hospital, diversity, equity, and inclusion are at the core of our values and mission for all of our patients and families that we serve. We are committed to providing a diverse and inclusive work environment for all faculty, staff and learners throughout our organization. We believe that each member of our one amazing team provides enrichment that allows us to create a lasting legacy for future employees of this great organization.   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.

Summary:

We are searching for a UM Denial Coordinator LVN -- someone who works well in a fast-paced setting. In this position, using a collaborative approach, the licensed vocational nurse (LVN) denial coordinator will work with Texas Children's Health Plan (TCHP) medical directors/physician reviewers, network physicians, and network facilities to ensure consistent clinical evaluation and processing of cases not meeting TCHP medical necessity criteria for reasons of medical necessity decisions. Documentation of these decisions and precise record-keeping of notice to Members and network providers is essential in complying with the legal statute and accrediting standards supporting consumer rights.

 

Think you’ve got what it takes



Responsibilities :

  • Reviews cases sent by TCHP Utilization Reviewer to establish of criteria application and time frame of processing meet conditions for denial
  • Teams with the physician team to identify a strategy for action and to be used as well as a choice of guideline citation/response based on the category of denial
  • Identifies problems/barriers/opportunities in the process and provides for resolution, and revision of plans on an ongoing basis
  • Serves as a Flex team – reviews authorization for inpatient and outpatient requests and processes per established criteria and or guidelines for the appropriate benefit, service, and level of care or setting for the delivery of care and or service
  • Communicates with internal staff, physicians, hospital representatives, and other providers on status of case review and due process and explanation of rationale, process, and regulatory processing
  • Collaborates with other reviewers, medical directors, external physician reviewers, and network providers
  • Educates physician reviewers and nursing staff on policies and procedures of the Texas Children’s Health Plan managed care and Medicaid
  • Established integrity of the review process of denial compliance and policies and procedures of the Texas Children’s Health Plan, managed care, and Medicaid through informing and auditing practice
  • Provides audits on physician and nursing staff based upon audit findings, developing coaching plans based upon findings
  • Develops and analyzes quarterly reports for the Clinical Advisory Committee, Quality Improvement Committee, and TCHP Leadership to address outcome data to assist in the identification of improvement opportunities


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
  • Graduation from an accredited School of Vocational Nursing
  • LVN - Lic-Licensed Vocational Nurses by the State of Texas
  • Required 5 years of Utilization Management experience and a preferred 3 years of Denial or Appeal experience


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