On Site Utilization Management Coordinator - Registered Nurse (RN)

Blue Cross Blue Shield of IL, MT, NM, OK & TX - Dallas, TX3.9

30 days ago
** This position is based in office in Dallas, TX and has field based travel to hospitals in DFW mostly in Downtown Dallas. **
The initial training for this role will be in Richardson, TX and Downtown Dallas.

BASIC FUNCTION:
This position is responsible performing initial, concurrent review activities; discharge care coordination for determining efficiency, effectiveness and quality of medical/surgical services and serving as liaison between providers and Medical and Network Management Divisions. This position conducts on-site reviews and assessments, reviews service requests, collects clinical and non-clinical data, verifies eligibility, determines benefit levels in accordance to contract guidelines, prepares reports on quality of care, identifies and reports cases, and provides information regarding utilization management requirements and operational procedures to members, providers and facilities.

JOB REQUIREMENTS:
  • Registered Nurse (RN) with valid, current, unrestricted license in The State of Texas.
  • 3 years of clinical experience in physician office, hospital/surgical setting or health insurance company.
  • Knowledge of medical terminology and procedures.
  • Verbal and written communication skills.
  • Willingness and ability to travel.
PREFERRED JOB REQUIREMENTS:
  • Utilization Management (UM) experience.
  • MCG Certification.
  • Knowledge of Milliman Guidelines or similar clinical guidelines
  • Knowledge of medical management policies and procedures
  • Prior experience working with a Dedicated Unit or supporting a Custom Account.
HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

Requirements:
Expertise Nursing
Job Type Full-Time Regular
Location TX - Dallas
HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants.

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