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. Additional Information: The RN Reviewer/Utilization Management will coordinate the efficient utilization of health care resources for Cook Children's Health Plan (CCHP) members. This role will mainly coordinate members needing Behavioral Health and outpatient procedures but must be willing to cross-train in different areas.
The RN will work closely with the Department Manager and Team Lead to assure the timely provision of quality care throughout the continuum of care. The RN Reviewer facilitates clinically appropriate and fiscally responsible care through communication with the providers and health plan medical directors. Will assess and identify the members clinical information and determine, 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/Experience: Associate degree of Nursing required, BSN preferred. RN with a minimum of five (5) years clinical experience. 2 years utilization management or case management experience required. Critical Care and discharge planning experience preferred.
Experience with Behavioral Health preferred. Skills Required: Strong organizational and time-management skills, with the ability to effectively prioritize multiple tasks and work efficiently across a variety of electronic platforms and systems. Demonstrates exceptional oral and written communication, applies strong critical-thinking and problem-solving skills, and delivers responsive, customer-focused service while effectively managing diverse needs and priorities.
Ability to work in fast-paced environment and meet deadlines. Certification/Licensure: Current unrestricted RN licensure in the State of Texas.
Cook Children’s is an equal opportunity employer. As such, Cook Children’s 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.
Cook Children’s is a Texas-only employer. If you are hired, you will need to maintain your primary residence within the state of Texas, along with all licenses and credentials required for your position throughout your employment.