Utilization Management Clinical Registered Nurse

We’re searching for a Utilization Management Clinical Registered Nurse, someone who works well in a fast-paced setting. In this position, you’ll be responsible for providing precertification of inpatient hospitalizations and all outpatient procedures and services requiring authorization and performing telephonic and/or concurrent review of inpatient hospitalizations and extended courses of outpatient treatment.  

Think you’ve got what it takes?

Job Duties & Responsibilities

• Analyzes unique situation of request, identifying appropriate guideline and regulatory requirements for each request
• Applies clinical decision making to assessment of clinical acuity and appropriateness of suggested treatment/services
• Creates a case summary evaluation for requests failing medical necessity criteria, and has collaborative discussion with the medical director or designee for review and disposition
• Researches clinical guidelines for potential investigative service requests, researches weekly changes to Medicaid manual to assure coverage determinations, and maintains currency of clinical guideline elements
• Ensures the timeliness of all denial letters within the regulations mandated
• Creates communication pieces to providers, which meet accrediting and regulatory guidelines for clinical content and readability levels describing decision making rationale for service requests and notifies providers through written correspondence
• Collaborates with all disciplines within the health plan to meet goals and objectives meeting with contracting and provider relations on routine basis
• Screens, identifies, and refers potential members to case management and evaluation for programs or coverage
• Identifies potential quality of care issues, and/or fraud and abuse, and refers to appropriate department 
   

As part of our commitment to maintaining a safe and healthy workplace, all successful candidates will be required to undergo respiratory fit testing in compliance with occupational health and safety standards.  

Skills & Requirements 

• Diploma in nursing required or
• Associates 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 required or
• Bachelor's degree in nursing preferred
• RN - Lic-Registered Nurses by Texas Board of Nursing or Nursing Licensure Compact required
• 3 years of nursing experience required