Utilization Management (UM) nurses will assist in the management of CHC members in assessing authorization needs, proper data entry of authorization in the UM system, and assist with approval of requested services/treatments utilizing nationally recognized clinical criteria. They will handle incoming calls with regarding requests for authorizations or questions regarding the authorization process. They offer alternative and supplemental recommendations for services available in the community. Referral processing of requests for in patient care, Home Health Care, and durable medical equipment requests through coordination of CHC resources. They use their nursing knowledge and background to screen and review clinical information for the most appropriate service areas within CHC, making referrals to High-Risk Perinatal Group, Case Management and Disease Management. The nurse will work closely with the Medical Directors in referral of requests that do not meet the screening criteria used by nursing staff.

Minimum Qualifications

Education/Specialized Training/Licensure: minimum-LVN with current Texas License

Work Experience (Years and Area): Prefer 3-5 years clinical experience in an acute care setting. At least 1 year insurance related experience in a managed care environment. Familiarity with the use of Medical Codes is preferred.

Equipment Operated: Computer literate with knowledge of Word, Excel, and Outlook. .


Special Requirements

Communication Skills: Above Average Verbal (Heavy Public Contact) Writing/composing, (Correspondence/Reports)

Other Skills: Analytical, Medical Terminology, P.C., Typing (wpm)

Work Schedule: Days 8-5 p.m., Flexible, Travel

Other Requirements: Able to work independently under general instructions and working with a Team
Must have reliable transportation