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.
- Required current RN (ADN or BSN), unrestricted license in the state of Texas
- Prefer 3-5 years clinical experience in an acute care setting.
- Prefer at least one year of utilization review experience in a managed care environment.
- Communication Skills: Exceptional Verbal and written
- Analytical, Mathematics, Medical Terms, MS Word, MS Excel
- CCM preferred
- Able to work independently under general instructions and working within a team environment, Able to apply the nursing process and use critical thinking.