JOB SUMMARY

The UM RN will perform utilization review of Community members requiring authorization for health services. The UM RN will help ensure proper data entry of authorization in the managed care platform and initiate the approval process for requested services/treatments utilizing nationally recognized evidenced based clinical criteria and/or internal policy's, protocols, and procedures. The UM RN will screen and review clinical information for the most appropriate service areas within Community, making referrals to high risk perinatal team, complex case management and disease management. The UM RN will work closely with the Medical Directors and refer requests that do not meet medical necessity criteria. The UM RN has heavy telephonic and facsimile contact with providers and their representatives. The UM RN will be responsible for meeting required performance and quality metrics within established timelines. Telecommuter opportunity after successfully meeting performance goals.

JOB SPECIFICATIONS

Essential Functions
1. Review telephonic and faxed clinical information to authorize medically necessary inpatient and outpatient care, utilizing nationally recognized evidenced based clinical criteria or approved medical guidelines. Refers cases that do not meet criteria to Medical Director for review.
2. Assists in discharge planning especially Home Health Nursing requests and DME requests for members at the time of discharge as well as new requests for members who have not had recent hospitalization. Review any requests for extension of these services and if not meeting criteria, refer to the Medical Director.
3. Participates in Community Nursing Rounds if applicable with Medical Director and is adequately prepared. Assists co-workers with difficult cases through open discussion. Communicates concerns that arise in these discussions to the Manager and/or Medical Director.
4. Maintains knowledge of the designated referral and provider software systems. Verifies member eligibility, benefit coverage and facility contract status prior to processing authorization requests. Accurately enters the required information into the managed care platform, adhering to UM policies and procedures.
5. Assists in the coordination of care of hospitalized members, medically complex members and members with special needs if applicable. Makes appropriate referrals and follow up to other Community programs/departments.
6. Meets required performance metrics for cases reviewed within established turnaround times. Meets established quality standards
7. Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans.
8. Demonstrates Harris Health and Community Health Choice values, including trust, integrity, mutual respect, diversity, responsiveness and caring service.

Marginal Functions
9. Other duties as assigned.

MINIMUM QUALIFICATIONS:

Education/Specialized Training/Licensure: RN, current Texas License or current in a National Licensure Compact participating state) required.

Work Experience (Years and Area): Three years clinical experience in acute setting required.

Software Proficiencies: Microsoft Office (Word, Outlook, Excel)