UM/CM Nurse

Dean’s Professional Services

Houston, TX, USA

Full time

$50-50 (hourly)

Jan 6

Dean’s Professional Services is now hiring for qualified, patient-care focused UM/CM Nurse to work in the Houston, TX area for a large Healthcare Organization.

UM/CM Nurse help ensure proper data entry of authorization in the managed care platform and initiate the approval process for requested services/treatments utilizing nationally recognized evidence based clinical criteria and/or internal policy’s, protocols, and procedures.

 Job Responsibilities:

  • 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.
  • 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.
  • 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.
  • 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.
  • 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.

 Job Requirements:

  • RN Current TEXAS license
  • 3 years clinical experience in acute setting
  • Microsoft Office (Word, Outlook, Excel)
  • 60-90 training with a possibility of becoming REMOTE (depending upon your productivity)
  • Familiar with software (MILLIMAN , INTERQUAL)
  • MUST have 1 yr. + of recent RN Case Management, RN Care Coordinator, Utilization Review, Utilization Specialist, Discharge Planning experience (REQUIRED)
  • Medicaid experience preferred

 PLEASE CALL 713-785-7483

MUST BE AVALIABLE TO START ASAP

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