Responsible for the coordination and efficient utilization of health care resources for Cook Children's 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 member's 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.
Registered Nurse; minimum of five (5) years clinical experience; BSN preferred.
2 years utilization management or case management experience required.
Strong skills in the following areas: Oral and written communication, Critical thinking, Organization and time management, and Customer service.
Current unrestricted Registered Nurse licensure in the State of Texas.