Direct Employer
Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Requires an RN with unrestricted active license.Fundamental ComponentsUtilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
Direct Employer
Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services.Schedule is Monday-Friday standard business hours.No nights!Rotating weekends (3) and holidays(1).Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management functionGathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care(*) Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)(*) Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment(*) Identifies members who may benefit from care management programs and facilitates referral(*) Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization(*)
Staffing Company
We are seeking an RN or LVN Case Manager who is highly-organized, able to work in a team-oriented environment, be computer savvy, able to communicate clearly and have outstanding customer service.As a Utilization Case Manager you will:Work with complex cases to promote the delivery of quality, cost-effective health careWork with other members of the team to plan and review level of care, length of stay and general patient needs.Review & screen incoming referral requests for medical necessityReview medical recordsWhat We Need from You:Current Registered Nurse (RN) or Licensed Vocational Nurse (LVN) in TXMust have experience processing referral requestsExperience with Utilization Review or strong Case Manager is requiredStrong computer and electronic medical record skillsPassionate about quality patient care