Location:

　　Calmont Operations Building

　　Department:

　　Utilization

　　Shift:

　　First Shift (United States of America)

　　Standard Weekly Hours:

　　40

　　Summary:

　　Responsible for the coordination and efficient utilization of health care resources for Cook Children's Health Plan (CCHP) members. Works with the Department Manager and Team Lead to ensure the timely provision of quality care throughout the continuum of care.

　　Additional Information:

　　The RN - Behavioral Health UM Reviewer duties include:

　　Facilitates clinically appropriate and fiscally responsible care through communication with the providers and health plan medical directors.Assesses and identifies the members' clinical information and determines, in conjunction with the Medical Director, the medical necessity and appropriateness of requested services.Utilizes Medical Management Committee (MMC) approved clinical criteria to authorize requested services for the member.Communicate with providers of care/services to facilitate appropriate care transitions.Assures adherence to regulatory/contractually required timeliness standards for authorization request processing, associated communications, and notice of adverse determinations are met for CCHP.

　　Work Hours: 8am - 5pm Mon-Fri

　　Remote position after 1 month of training but candidate must be within driving distance to Fort Worth as they will be required to come in any time there is a fair hearing, mandatory staff training, etc.

　　Required Education & Experience:

　　Registered Nurse; BSN preferred.Behavioral Health Experience is strongly preferred.Minimum of five (5) years clinical experience required.2 years of utilization management or case management experience required.Strong skills in the following areas: Oral and written communication, Critical thinking, Organization and time management, and Customer service

　　Certification/Licensure:

　　Current unrestricted Registered Nurse licensure in the State of Texas.

　　About Us:

　　Cook Children's Health Plan

　　Cook Children's Health Plan provides vital coverage to nearly 120,000 people in low-income families who qualify for government-sponsored programs in our six county service region. Cook Children's Health Plan provides health coverage for CHIP, CHIP Perinatal, STAR (Medicaid) and STAR Kids Members in the Tarrant county service area. The counties we serve includes Tarrant, Johnson, Denton, Parker, Hood and Wise.

　　Cook Children's is an EOE/AA, Minority/Female/Disability/Veteran employer.