Um/ecm - Rn Reviewer Hp

Cook Children's Health Plan

Unknown, United States
Not specified
Clinical information assessment
Medical necessity determination
Provider communication skills
Cook Children's Health Plan is seeking a Registered Nurse Utilization Management/Episodic Case Manager (UM/ECM - RN) Reviewer to coordinate healthcare resources for its members. The role requires assessing clinical information, determining medical necessity, and ensuring adherence to regulatory standards

Job Summary

  • The role is responsible for coordinating and efficiently utilizing healthcare resources for Cook Children's Health Plan members.
  • The reviewer assesses clinical information to determine medical necessity in conjunction with the Medical Director using approved clinical criteria.
  • The position requires ensuring adherence to regulatory and contractually required timeliness standards for authorization processing and adverse determinations.

Matching Summary

Match Score: 85

Cook Children's Health Plan is seeking a Registered Nurse Utilization Management/Episodic Case Manager (UM/ECM - RN) Reviewer to coordinate healthcare resources for its members. The role requires assessing clinical information, determining medical necessity, and ensuring adherence to regulatory standards.

Skills & Requirements

Must-have

  • Clinical information assessment
  • Medical necessity determination
  • Provider communication skills
  • Regulatory timeliness adherence
  • Care transition facilitation

Nice-to-have

  • Critical thinking abilities
  • Strong organization skills
  • Customer service orientation
  • Time management expertise

Key Requirements

  • Current unrestricted Registered Nurse licensure in Texas
  • Associate degree of Nursing required, BSN preferred
  • Minimum 5 years clinical experience
  • 2 years utilization or case management experience

Work Rights

Not specified

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