Utilization Management Clinical Registered Nurse

At our company, our mission starts with our people. Guided by our HEART values—Humility, Excellence, Accountability, Respect, and Trust—we strive to create a workplace where teammates feel valued, supported, and empowered to do their best work every day. As a Utilization Management Clinical RN, you’ll provide precertification of inpatient hospitalizations and all outpatient procedures and services requiring authorization, and perform telephonic and/or concurrent review of inpatient hospitalizations and extended courses of outpatient treatment. 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 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