Clinical Utilization Manager RN
5 days ago
We are seeking a skilled Utilization Management Clinical RN to join our team at Texas Children's Hospital. As a Utilization Management Clinical RN, you will play a critical role in ensuring that our patients receive the most appropriate and cost-effective care.
Key Responsibilities:- Analyze submitted information, including clinical assessments, treatment plans, regulatory guidelines, medical necessity, and accrediting standards, to determine the appropriateness of services.
- Collaborate with medical directors and other healthcare professionals to review and disposition requests that fail medical necessity criteria.
- Document due process, attempts to gain adequate clinical information, and reviews all denial letters for accuracy and adherence to policy and procedure.
- Develop communication pieces to providers that meet accrediting and regulatory guidelines, describing decision-making rationale for service requests and notifying providers through written correspondence.
- Work closely with all disciplines within the health plan to meet goals and objectives, including contracting and provider relations.
- Develop recommendations for care planning based on projected course of treatment and prognosis analysis.
- Conduct cost-benefit analyses in situations where coverage outside of benefits needs to be evaluated due to unique member situations.
- 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.
Why Join Our Team?
As a Utilization Management Clinical RN at Texas Children's Hospital, you will have the opportunity to work with a talented team of healthcare professionals who are dedicated to providing high-quality care to our patients. You will have the chance to develop your skills and expertise in utilization management, and contribute to the development of policies and procedures that promote efficient and effective care.
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Clinical Utilization Manager
3 days ago
Bellaire, Texas, United States Texas Children's Hospital Full timeJob Title: Utilization Management Clinical RNWe are seeking a skilled Utilization Management Clinical RN to join our team at Texas Children's Hospital. As a Utilization Management Clinical RN, you will play a critical role in ensuring that our patients receive the most appropriate and cost-effective care.Responsibilities:Analyze submitted information,...
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Clinical Utilization Manager
3 days ago
Bellaire, Texas, United States Texas Children's Hospital Full timeJob Title: Utilization Management Clinical RNWe are seeking a skilled Utilization Management Clinical RN to join our team at Texas Children's Hospital. As a key member of our healthcare team, you will play a critical role in ensuring that our patients receive the most appropriate and cost-effective care.Responsibilities:Analyze submitted information,...
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