Clinical Utilization Management RN
3 weeks 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 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.
- 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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Clinical Utilization Management RN
4 weeks 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.Key Responsibilities:Analyze submitted information,...
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Clinical Utilization Manager
1 month 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
1 month 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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Clinical Utilization Manager RN
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Bellaire, Texas, United States Texas Children's Hospital Full timeUtilization Management Clinical RNWe are seeking a skilled Utilization Management Clinical RN to join our team at Texas Children's Hospital. In this role, you will play a critical part in ensuring the efficient use of healthcare resources while maintaining high-quality patient care.Key Responsibilities:Analyze submitted information, including clinical...
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Clinical Utilization Management RN
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Bellaire, Texas, United States Texas Children's Hospital Full timeAbout the RoleWe are seeking a skilled Clinical Utilization Management RN to join our team at Texas Children's Health Plan. As a Clinical Utilization Management RN, you will play a critical role in ensuring that our members receive the most appropriate and cost-effective care possible.Key ResponsibilitiesAnalyze submitted information, including clinical...
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