Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:

* Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women

* Childrens Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR

* Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.

* Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

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 policys, 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 AND CORE COMPETENCIES

Essential Functions

• 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.
• Meets required performance metrics for cases reviewed within established turnaround times. Meets established quality standards
• Actively contributes to achievement of departmental goals, as identified in Departments annual business plan, including specific departmental process improvement plans.
• Demonstrates Harris Health and Community Health Choice values, including trust, integrity, mutual respect, diversity, responsiveness and caring service.

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)