Utilization Management Clinical Registered Nurse
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Job Location:
Houston, MS - USA
Monthly Salary:
Not Disclosed
Posted on:
30+ days ago
Vacancies:
1 Vacancy
Job Summary
Were searching for a Utilization Management Clinical RN someone who works well in a fast-paced this position youll 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 youve 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 undergorespiratoryfit testing in compliance with occupational health and safety standards.
Skills & Requirements
- Diploma in nursing required or
- Associates degree in nursing or an associates degree in a related field accepted by the Texas Board of Nursing for the purposes of obtaining and maintaining an RN license required or
- Bachelors degree in nursing preferred
- RN - Lic-Registered Nurses by Texas Board of Nursing or Nursing Licensure Compact required
- 3 years of nursing experience required
Key Skills
- EMR Systems
- Hospital Experience
- Acute Care
- ICU Experience
- Hospice Care
- Workers' Compensation Law
- Home Care
- Nursing
- Catheterization
- Critical Care Experience
- Medication Administration
- Tube Feeding
About Company
Since 1954, Texas Children’s has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades suc ... View more
