UMECM RN Reviewer (Health Plan)

Location:

Department:

Shift:

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Summary:

Additional Information:

Responsible for the coordination and efficient utilization of health care resources for Cook Childrens Health Plan (CCHP) members. Works with the Department Manager and Team Lead to assure the timely provision of quality care throughout the continuum of care. The Registered Nurse Utilization Management/Episodic Case Manager (UM/ECM - RN) Reviewer facilitates clinically appropriate and fiscally responsible care through communication with the providers and health plan medical directors. The UM/ECM - RN Reviewer assesses and identifies the members clinical information and determines in conjunction with the Medical Director medical necessity and appropriateness of requested services. Utilizes Medical Management Committee (MMC) approved clinical criteria to authorize requested services for the member. The UM/ECM - RN Reviewer communicates with providers of care/services to facilitate appropriate care transitions. The UM/ECM - RN Reviewer assures adherence to regulatory/contractually required timeliness standards for authorization request processing associated communications and notice of adverse determinations are met for CCHP.

Education:

• Registered Nurse; BSN preferred.

• Minimum of five (5) years clinical experience

• 2 years utilization management or case management experience required.

Strong skills in the following areas: Oral and written communication; Critical thinking; Organization and time management; Customer service.

Certification/Licensure:

• Current unrestricted Registered Nurse licensure in the State of Texas.

About Us:

Cook Childrens Health Plan

Cook Childrens Health Plan provides vital coverage to nearly 120000 people in low-income families who qualify for government-sponsored programs in our six county service region. Cook Childrens Health Plan provides health coverage for CHIP CHIP Perinatal STAR (Medicaid) and STAR Kids Members in the Tarrant county service area. The counties we serve includes Tarrant Johnson Denton Parker Hood and Wise.

Cook Childrens is an equal opportunity employer. As such Cook Childrens offers equal employment opportunities without regard to race color religion sex age national origin physical or mental disability pregnancy protected veteran status genetic information or any other protected class in accordance with applicable federal laws. These opportunities include terms conditions and privileges of employment including but not limited to hiring job placement training compensation discipline advancement and termination.