Parkland Community Health Plan's (PCHP's) Utilization Management (UM) Nurse is responsible for the management of members requiring care for continued services such as hospitalizations including discharge planning and transitions of care. Oversees the application of clinical guidelines in determining appropriateness of requested and continued healthcare services. Ensures that all clinical decisions are completed according to evidence based best practice guidelines and meets regulatory requirements. Seeks Medical Director input for review of cases not meeting criteria and monitors time frames for decision making and notifications of decision.
- Must be a graduate of an accredited school of nursing.
- Bachelor's degree in Nursing is preferred.
- Five (5) years of experience in an acute clinical nursing or medical management setting.
- Knowledge of utilization management and case management principles is preferred.
- Experience in Texas Medicaid and NCQA is preferred.
- Three (3) years of managed care experience is preferred.
Equivalent Education and/or Experience - May have an equivalent combination of education and experience to substitute for the experience requirements.
- Must have a current, unrestricted RN license to practice nursing in the State of Texas (or compact license).
Skills or Special Abilities
- Clear and professional verbal and written communication skills.
- Proficient in Microsoft Word, Excel and Power Point.
- Competent in UM functions including application of InterQual criteria.
- Ability to analyze clinical information and accurately apply clinical criteria.
- Proficient in medical and managed care terminology.
- Knowledge of NCQA, Federal and Texas Medicaid Utilization Management (UM) regulations.
- Ability to analyze and resolve complex and conflicting information and manage multiple deadlines.
- Knowledge of and competence in use of UM software.
- Ability to multitask between computer, fax and multi-line phone requests.
- Performs utilization review activities including pre-certification, concurrent, and retrospective reviews according to guidelines and refers to the Medical Director those that require additional expertise.
- Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
- Answers utilization management directed telephone calls; managing them in a professional and competent manner. Conducts ongoing availability, monitoring, and oversight of non-clinical staff activities.
- Uses effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to assure appropriate levels of care are received by members
- Provides appropriate consultation and referral to case management.
- Identifies and utilizes appropriate alternative and non-traditional available resources in managing cases.
- Maintains accurate records of all communications and interventions and provides timely reports as directed.
1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.
Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.
Nearest Major Market: Dallas
Nearest Secondary Market: Fort Worth
Job Segment: Nursing, Medical, Manager, Patient Care, Registered Nurse, Healthcare, Management