Clinical Utilization Management RN

24 hours ago


Houston, Texas, United States Texas Children's Hospital Full time
About the Role

We 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 Responsibilities
  • Analyze submitted information, including clinical assessments, treatment plans, regulatory guidelines, medical necessity, and accrediting standards for all requests.
  • Create a case summary evaluation for requests failing medical necessity criteria, and have collaborative discussion with the medical director or designee for review and disposition.
  • Document due process, attempts to gain adequate clinical information to analyze for decision, reviews all denial letters for appropriate regulatory verbiage, accuracy of the member plan type, and adherence to applicable policy and procedure with regards to the denial letter process.
  • Create communication pieces to providers that meet accrediting and regulatory guidelines for clinical content and readability levels describing decision-making rationale for service requests and notify providers through written correspondence.
  • Collaborate with all disciplines within the health plan to meet goals and objectives, meeting with contracting and provider relations on a routine basis.
  • Create a cost-benefit analysis in situations where coverage outside of benefits needs to be evaluated due to unique member situations and deliver that to the medical director/designee.
  • Work closely with UM Analyst staff to expedite appeals and complaint process by coordination of concurrent activity with policy and procedure requirements.
About Us

Texas Children's Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children, and adults in Houston and surrounding areas.

Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals.

Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.

We are proud to be an equal opportunity employer and value diversity and inclusion in the workplace.



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