Utilization Management (UM) LVN - 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
Utilization Management (UM) nurses will assist in the management of CHC members in assessing authorization needs, proper data entry of authorization in the UM system, and assist with approval of requested services/treatments utilizing nationally recognized clinical criteria .They will handle incoming calls with regarding requests for authorizations or questions regarding the authorization process. They offer alternative and supplemental recommendations for services available in the community. Referral processing of requests for in patient care, Home Health Care, and durable medical equipment requests through coordination of CHC resources. They use their nursing knowledge and background to screen and review clinical information for the most appropriate service areas within CHC; making referrals to High Risk Perinatal Group, Case Management and Disease Management . The nurse will work closely with the Medical Directors in referral of requests that do not meet the screening criteria used by nursing staff.
Education/Specialized Training/Licensure: minimum-LVN with current Texas License
Work Experience (Years and Area): Prefer 3-5 years clinical experience in an acute care setting. At least 1 year insurance related experience in a managed care environment. Familiarity with the use of Medical Codes is preferred..
Equipment Operated: Computer literate with knowledge of Word, Excel, and Outlook. .
Communication Skills: Above Average Verbal (Heavy Public Contact) Writing/composing, (Correspondence/Reports)
Other Skills: Analytical, Medical Terminology, P.C., Typing (wpm)
Work Schedule: Days 8-5 p.m., Flexible, Travel
Other Requirements: Able to work independently under general instructions and working with a Team
Must have reliable transportation