About this role
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