Clinical Utilization Management RN

3 weeks 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 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 requests.
  • Create case summaries and collaborate with medical directors to review and disposition requests that fail medical necessity criteria.
  • Document due process, attempts to gain adequate clinical information, and reviews of denial letters to ensure 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.
  • Collaborate with all disciplines within the health plan to meet goals and objectives, including routine meetings with contracting and provider relations.
  • Develop recommendations for care planning based on projected treatment courses and prognosis analysis.
  • Conduct cost-benefit analyses in situations where coverage outside of benefits needs to be evaluated and deliver recommendations to medical directors.
  • Work closely with UM Analyst staff to expedite appeals and complaint processes by coordinating concurrent activity with policy and procedure requirements.
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 of nursing experience required.
  • Experience with Utilization Management or Case Management preferred.

We offer a dynamic and supportive work environment, competitive compensation, and opportunities for professional growth and development. If you are a motivated and detail-oriented RN with a passion for Utilization Management, we encourage you to apply for this exciting opportunity.



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