Clinical Utilization Manager

7 hours ago


Bellaire, Texas, United States Texas Children's Hospital Full time
Job Title: Utilization Management Clinical RN

We 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, including clinical assessments, treatment plans, regulatory guidelines, medical necessity, and accrediting standards, to determine the appropriateness of requests.
  • Create case summaries and evaluations for requests that fail medical necessity criteria, and collaborate with the medical director or designee for review and disposition.
  • Document due process, attempts to gain adequate clinical information, and reviews all denial letters for accuracy and adherence to applicable policy and procedure.
  • Develop communication pieces to providers that meet accrediting and regulatory guidelines for clinical content and readability levels, describing decision-making rationale for service requests and notifying providers through written correspondence.
  • Collaborate with all disciplines within the health plan to meet goals and objectives, including meeting with contracting and provider relations on a routine basis.
  • Create recommendations for care planning based on projected course of treatment and prognosis analysis, and develop cost-benefit analyses in situations where coverage outside of benefits needs to be evaluated.
Requirements:
  • 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?

At Texas Children's Hospital, we are committed to providing exceptional patient care and improving the health of children through innovative research and education. As a Utilization Management Clinical RN, you will have the opportunity to work with a talented team of healthcare professionals who share your passion for delivering high-quality care.

What We Offer:

We offer a competitive salary and benefits package, as well as opportunities for professional growth and development. If you are a motivated and compassionate healthcare professional who is committed to delivering exceptional patient care, we encourage you to apply for this exciting opportunity.



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