Clinical Utilization Management Specialist

4 weeks ago


Tyler, Texas, United States Christus Health Full time

Job Summary:

The Utilization Management Nurse II is a key member of the healthcare team at Christus Health, responsible for ensuring the clinical appropriateness of care provided to patients and optimizing hospital resource utilization. This role requires a strong clinical background, excellent communication skills, and the ability to work effectively in a fast-paced environment.

Key Responsibilities:

  • Conduct comprehensive assessments of clinical information and treatment plans to determine medical necessity and level of care.
  • Utilize approved screening criteria to assess the appropriateness of care and services.
  • Collaborate with the interdisciplinary team to ensure seamless patient care progression and effective communication with payors.
  • Proactively identify and resolve issues related to clinical appropriateness recommendations, coverage, and potential or actual payor denials.
  • Develop and maintain knowledge of regulatory requirements, payor guidelines, and Joint Commission regulations to ensure compliance.
  • Effectively communicate with internal and external stakeholders, including physicians, payors, patients, and families.
  • Stay up-to-date with industry trends, best practices, and emerging technologies to optimize utilization management processes.

Requirements:

  • Graduate of an accredited School of Nursing or demonstrated success in the Utilization Management Nurse I role for at least five years at Christus Health.
  • Two or more years of clinical experience with at least one year in the acute care setting or demonstrated success as Utilization Management Nurse I role at Christus Health.
  • RN License in state of employment or compact required. LPN or LVN license accepted for associates with 5+ years of demonstrated success and experience in the Utilization Management Nurse I role at Christus Health.
  • Certification in Case Management preferred. BLS preferred.

Work Schedule: 8AM - 5PM Monday-Friday. Work Type: Full Time.



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