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

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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