PRN Utilization Management 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.
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
JOB SUMMARY: The UM RN performs utilization review of Community members requiring authorization for health services. The UM RN helps 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 policy¿s, protocols, and procedures. This position screens and reviews clinical information for the most appropriate service areas within Community; makes referrals to high risk perinatal team, complex case management and disease management. The UM RN works closely with the Medical Directors and refers requests that do not meet medical necessity criteria. The UM RN has heavy telephonic and facsimile contact with providers and their representatives and is responsible for meeting required performance and quality metrics within established timelines.
1. Education/Specialized Training/Licensure: RN, Associates Degree required, BSN preferred, unrestricted TX license required
2. Work Experience (Years and Area): Two years clinical experience in an acute care setting. One year of utilization management experience in a managed care environment required.
3. Management Experience (Years and Area): N/A
4. Software Operated: Microsoft Office (Word, Outlook, Excel)
SPECIAL REQUIREMENTS: (Check Applicable Areas)
1. Communication Skills:
Above Average Verbal (Heavy Public Contact)
Writing /Composing: Correspondence / Reports
2. Other Skills: Analytical, Mathematics, Medical Terminology, MS Word
3. Advanced Education:
Bachelors Degree Major: BSN Preferred
4. Work Schedule: 8hr Weekends
5. 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.