Clinical assessment and medical necessity determination
Authorization request processing
The Registered Nurse Utilization Management/Episodic Case Manager Reviewer facilitates clinically appropriate and fiscally responsible care through communication with providers and health plan medical directors
Job Summary
The Registered Nurse Utilization Management/Episodic Case Manager Reviewer facilitates clinically appropriate and fiscally responsible care through communication with providers and health plan medical directors.
The UM/ECM - RN Reviewer utilizes Medical Management Committee approved clinical criteria to authorize requested services for members.
Cook Children's Health Plan provides vital coverage to nearly 120,000 people in low-income families who qualify for government-sponsored programs in our six county service region.
Matching Summary
The Registered Nurse Utilization Management/Episodic Case Manager Reviewer facilitates clinically appropriate and fiscally responsible care through communication with providers and health plan medical directors.
Skills & Requirements
Must-have
Utilization management expertise
Clinical assessment and medical necessity determination
Authorization request processing
Communication with healthcare providers
Adherence to regulatory timeliness standards
Nice-to-have
Critical thinking skills
Organization and time management
Customer service skills
Oral and written communication
Key Requirements
Registered Nurse licensure in Texas
Minimum five years clinical experience
Two years utilization or case management experience