Review inpatient admissions to assure appropriate level of care and medical necessity.
Review admissions through on-site and telephonic review to ensure medical necessity and appropriate level of care. Act as clinical resources to referral staff and make appropriate referrals. Provide patient and provider education. Data enters assessments, authorizations and reviews into the system. THIS position will work partially in the office and partially on-site at the hospitals.

Perform utilization review for outpatient services. Review prior authorization requests utilizing approved criteria/guidelines to ensure the medical necessity of requested services/procedures.
Gather, collect, and document information necessary for the review of prior authorization requests received via fax or telephone from providers into designated systems according to procedure.
Refer cases not meeting criteria/guidelines for physician review. Communicate review outcomes to providers per protocol. Act as a clinical resource to referral staff. Provide patient and provider education.

Review and analyze reports, records and directives.
Confer with staff to obtain data such as new projects, status of work in progress, and problems encountered, required for planning work function activities. Verify data to be submitted in accordance with government program requirements and ensure compliance with state, federal and certification requirements.
Prepare reports and records on work function activities for management.
Oversee the review and analysis of reports.
Evaluate current procedures and practices for accomplishing the assigned work functions objectives to develop and implement improved procedures and practices and to ensure compliance with required standards.
Collaborate with appropriate departments to document, investigate and resolve formal or informal complaints and appeals in accordance with Company and State policies, procedures and requirements.
Monitor and analyze costs and participate in the preparation of the budget.

Review analyses of activities, costs, operations and forecast data to determine progress toward stated goals and objectives. Promote compliance with federal and state regulations and contractual agreements. Develop, implement and maintain compliance, policies and procedures regarding medical utilization management functions. Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and decrease health plan financial exposure. Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management. Facilitate on-going communication between utilization management staff and contracted providers. Develop staff skills and competencies through training and experience.

Profession: Nursing
Specialty: Nurse Management
Sub specialty: Operating Room-Nurse Manager
Functionality: Hospital
Type of job: Full time

ESSENTIAL FUNCTIONS:
1. Provides advance neonatal nursing practice coverage for high-risk neonates.
2. Performs comprehensive diagnostic and physical assessments to guide development of the medical plan of care in collaboration with the attending physicians.
3. Performs designated diagnostic and clinical procedures as defined in an agreed advanced practice protocol.
4. Participates in the ongoing and yearly revision and implementation of the updated advance practice protocol.
5. Documents concisely accurately and legibly in the medical record.
6. Identifies opportunities for improvement and participates in research development education communication and implementation of system changes and committees.
7. Monitors and evaluates the quality and appropriateness of care and practices through collaboration within the multidisciplinary team.
8. Promotes teamwork and serves as a role model consultant delegator educator and resource for members of the health care team and families.
9. Evaluates and applies knowledge of age-related and socioeconomic factors in the assessment care treatment and education of neonatal patients and their families.
10. Other duties as assigned.

EDUCATION REQUIRED AND OR PREFERRED:
REQUIRED: Completion of an NLN accredited school of nursing program; completion of an approved Neonatal Nurse Practitioner Program.
PREFERRED: Advanced nursing degree
-Certifications Required: NRP

LICENSURE CERTIFICATION:
REQUIRED: Current RN licensure in Texas; concurrent approval to practice advanced nursing in the state of Texas; AAP Neonatal Resuscitation Program certification; NCC Neonatal Nurse Practitioner certification

EXPERIENCE REQUIRED OR PREFERRED:
REQUIRED: 2 Years Level III neonatal nursing

The qualified candidate will meet or excede these expectations.

As a Case Manager Prior Authorization RN your responsibilities will include but not be limited to the following:
- review requests for prior authorization for radiology services MRI?s CAT Scans etc.
- Act as clinical resources to referral staff and make appropriate referrals.
- Provide patient and provider education.
- Enters authorizations into the system

REQUIREMENTS:
- MUST be an RN
- Bachelor’s Degree in Nursing or other clinical degree
- At least two years clinical nursing experience
- Utilization Management UM certification preferred
- Experience in health care operations.
- Understanding of medical mgmt is very helpful

***** They will consider a candidate with no managed care IF they have strong discharge planning and or chart review and EXCELLENT track record overall.*************

THE COMPANY:
Our client is a leading multi-line health care enterprise that provides programs and related services to individuals receiving benefits under Medicaid including Supplemental Security Income SSI and the State Children?s Health Insurance Program SCHIP . The Company operates health plans in several states.

KEYWORDS: Case manager case management RN nurse CCM certified case manager utilization management utilization review UR UM managed care health plan health insurance

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Desired: ER or ICU experience.