Utilization Management (UM) RN (Community Health Choice)
Harris Health System
Location: Houston, Texas
Type: Full Time
Internal Number: 159691
JOB SUMMARY: The UM RN will perform utilization review of Community members requiring authorization for health services. The UM RN will help ensure proper data entry of authorization in the managed care platform, and initiate the approval process for requested services/treatments utilizing nationally recognized evidenced based clinical criteria and/or internal policies, protocols, and procedures. The UM RN will screen and review clinical information for the most appropriate service areas within Community; making referrals to high risk perinatal team, complex case management and disease management. The UM RN will work closely with the Medical Directors and refer requests that do not meet medical necessity criteria. The UM RN has heavy telephonic and facsimile contact with providers and their representatives. The UM RN will be responsible for meeting required performance and quality metrics within established timelines. Telecommuter opportunity after successfully meeting performance goals.
Education/Specialized Training/Licensure: Required current RN (ADN or BSN), unrestricted license in the state of Texas Work Experience (Years and Area): Prefer 3-5 years clinical experience in an acute care setting. Prefer at least 1 year of utilization review experience in a managed care environment. Equipment Operated: Computer literate with knowledge of Word, Outlook, Excel
SPECIAL REQUIREMENTS: Communication Skills: Above Average Verbal (Heavy Public Contact), Exceptional Verbal (e.g., Public Speaking), Writing /Composing, Correspondence / Reports
Other Skills: Analytical, Mathematics, Medical Terms, P.C., MS Word, MS Excel
Advance Training Specialty: CCM preferred
Other Requirements: Able to work independently under general instructions and working within a team environment, Able to apply the nursing process and use critical thinking.
The Harris Health System is a fully integrated healthcare system that cares for all residents of Harris County, Texas. We are the first accredited healthcare institution in Harris County to be designated by the National Committee for Quality Assurance as a Patient-Centered Medical Home, and are one of the largest systems in the country to achieve the quality standard. Our system includes 23 community health centers, five school-based clinics, a dental center and dialysis center, mobile health units, a rehabilitation and specialty hospital and two full-service hospitals.Ben Taub Hospital is a world renowned Level I Trauma Center with 586 licensed acute-care beds and provides a wide range of specialty care outpatient services. Lyndon B. Johnson Hospital is a 328 licensed bed acute-care hospital with a newly expanded Level III trauma center and a distinguished regional center for neonatal intensive care for high-risk deliveries.Harris Health is a teaching system for Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth). We train the next generation of healthcare providers on the latest medical procedures and technological breakthroughs.With... our fully integrated electronic medical records system, we offer patients the convenience and assurance that their medical history is accurate, safe and available when and where it is needed. Our Medical Home designation ensures that we offer a full range of preventive, specialty and acute care services for the entire family.