We are searching for a Utilization Management Clinical Support RN - someone who works well in a fast-paced setting. In this position you will support utilization management processes for the organization's health plan members. This role will oversee monitoring of service and productivity elements, educational support for staff, and processing of claims appeals that lack authorization of medical necessity. Think you've got what it takes?Qualifications:* Bachelor's, Associate in nursing, or diploma in nursing required* RN license with the Texas Board of Nursing required* 3 years of licensed nursing experience OR 5 years of utilization management experience requireResponsibilities:* Plan, develop, organize, direct, and implement a coordinated approach to the training of new staff and updating existing staff* Provide an analysis of authorization errors presented for review by the claims department* Coordinate activities of the appeals, complaints and fair hearing processes in a manner which adheres to IDS TCHP and other regulatory requirements* Support the delivery of utilization management services by understanding job functions of the unit and serving as a backup when staffing issues arise* Identify training opportunities and develop training curriculum in collaboration with manager and education department* Monitor appropriate work queues regularly for tracking appeals and fair hearing information, review and prep data as needed in preparation for appeal reviews and fair hearing meetings, assist in the coordination of fair hearing activities* Maintain current knowledge and contacts related to initial and concurrent review functions* Identify and develop specific programs and create educational training for staff in areas defined by trended data* Design and implement quality audits for clinical application of guidelines by reviewers and process improvement projects
Published: 2 weeks ago