Utilization Management (UM) RN (Community Health Choice)
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
Skills / Requirements
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
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.