Top 43 Utilization management Jobs in Beaumont, Tx

Utilization Management Nurse II - Case Management - Full Time
Christus Health —Beaumont, TX
- Overtime
- Nursing
- LVN
- RN License
12d
MDS Nurse - LVN
Jefferson Nursing and Rehabilitation Center —Beaumont, TX
- Full-time
- Nursing
- Skilled nursing facility
- LVN
Quick Apply
LTSS Service Coordinator (Hardin and Polk County)
Elevance Health —Beaumont, TX
- Monday to Friday
- Experience working with individuals with developmental disabilities
- Spanish
- Bachelor of Science
- Employee stock purchase plan
- Paid holidays
5d
Director, Clinical Operations
Astrana Health, Inc. —Beaumont, TX
- $90,000 - $130,000 a year
- Full-time
- Hybrid work
- SQL
- Clinic
- Analysis skills
Quick Apply
Certified Medication Aide (CMA) - Gist Unit
UTMB Health —Beaumont, TX
- Full-time
- Mid-level
- Ability to lift 50 pounds
- Military encouraged
QMHP/Case Manager
Houston Circle of Hope Services, Inc. —Beaumont, TX
- $24 - $27 an hour
- Full-time
- Mid-level
- Office
- Master's degree
Quick Apply
Cancer Center Program Administrator
Riceland Healthcare —Beaumont, TX
- $100,000 - $130,000 a year
- Full-time
- Nursing
- 5 years
- Clinic
- Health insurance
- Dental insurance
Quick Apply
4d
Provider Relations – Market Performance Lead
Astrana Health, Inc. —Beaumont, TX
- $80,000 - $90,000 a year
- Email
- Private practice
- Nursing
- Microsoft Excel
Quick Apply
Licensed Professional Counselor-Associate Salary Range: $51,614 / Annually
SPINDLETOP CENTER —Beaumont, TX
- $51,614 a year
- Weekends as needed
- LMFT
- Pass drug screening
- Licensed Clinical Social Worker
Longshore IME & Peer Review - Audiology
Dane Street, LLC —Beaumont, TX
- Contract
- Mid-level
- Analysis skills
Quick Apply
Advanced Practice Provider
NAUTILUS MEDICAL GROUP INC —Beaumont, TX
- Contract
- Nursing
- Doctoral degree
- Clinic experience
Quick Apply
QMHP - Bilingual (Beaumont, Texas)
Houston Circle of Hope Services, Inc. —Beaumont, TX
- $26 - $28 an hour
- Full-time
- Bilingual
- Mid-level
- Office
Quick Apply
Longshore IME & Peer Review - Otolaryngology
Dane Street, LLC —Beaumont, TX
- Contract
- BC/BE
- Analysis skills
- Senior level
Quick Apply
RN
Optum —Nederland, TX
- $75,450 - $87,000 a year
- Full-time
- CPR Certification
- RN License
- Writing skills
Quick Apply
Longshore IME & Peer Review - Psychiatry
Dane Street, LLC —Beaumont, TX
- Contract
- Psychiatry
- Analysis skills
- Senior level
Quick Apply
Hospital - Clinical Pharmacist Specialist (Bone Marrow Transplant)
UT Health Science Center at San Antonio —United States
- Hospital
- Outpatient experience
- 3 years
Quick Apply
Remote Physician (MD/DO), PMR or Neurology, Outpatient Prior Authorizations (REMOTE/FT) (IC to FTE)
Virtix Health —United States
- $125 an hour
- 8 hour shift
- Remote
- Background check
- Medicine
- Doctoral degree
- Work from home
Quick Apply
Manager, Case Management & Social Work – Up to $194k + Bonus
FocusPoint —United States
- Up to $194,272 a year
- Full-time
- Acute care
- Background check
- Nursing
- Health savings account
- Relocation assistance
Quick Apply
Behavioral Health Leadership & Clinical Contract / Interim Engagements
SimiTree Talent Solutions —United States
- Full-time
- Psychiatry
- Addiction Medicine
- Senior level
- Travel reimbursement
Quick Apply

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MDS Nurse - LVN
Jefferson Nursing and Rehabilitation Center —Beaumont, TX
Ensures that additional requirements of the Medicare Program are met, such as Physician certification and re-certification. Other duties as assigned or needed.
Quick Apply

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Utilization Management Specialist
ST VINCENT FAMILY SERVICES —Columbus, OH
Associate's Degree required; Bachelor's Degree preferred in Healthcare Administration, Business Administration, Social Work, Public Health, or related field.
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Utilization Review Specialist - Autism
Nationwide Children's Hospital —Columbus, OH
Bachelor’s Degree in Social Work, Psychology, or related field, required. Conducts utilization reviews of behavioral health cases to determine medical necessity…
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Utilization Management Nurse II - Case Management - Full Time

Christus Health -
Beaumont, TX

Apply Now

Job Details

Full-time
12 days ago

Qualifications

Utilization management

Full Job Description

Description

Summary:

The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services “CMS” Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and Joint Commission regulations and guidelines related to UM. This Nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Management Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.

Responsibilities:

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
Applies demonstrated clinical competency and judgment in order to perform comprehensive assessments of clinical information and treatment plans and apply medical necessity criteria in order to determine the appropriate level of care.
Resource/Utilization Management appropriateness: Assess assigned patient population for medical necessity, level of care, and appropriateness of setting and services. Utilizes MCG/InterQual Care Guidelines and/or health system-approved tools to track impact and variance.
Uses appropriate criteria sets for admission reviews, continued stay reviews, outlier reviews, and clinical appropriateness recommendations.
Coordinate and facilitate correct identification of patient status.
Analyze the quality and comprehensiveness of documentation and collaborate with the physician and treatment team to obtain documentation needed to support the level of care.
Facilitates joint decision-making with the interdisciplinary team regarding any changes in the patient status and/or negative outcomes in patient responses.
Demonstrates, maintains, and applies current knowledge of regulatory requirements relative to the work process in order to ensure compliance, i.e. IMM, Code 44.
Demonstrate adherence to the CORE values of CHRISTUS.
Utilize independent scope of practice to identify, evaluate and provide utilization review services for patients and analyze information supplied by physicians (or other clinical staff) to make timely review determinations, based on appropriate criteria and standards.
Take appropriate follow-up action when established criteria for utilization of services are not met.
Proactively refer cases to the physician advisor for medical necessity reviews, peer-to-peer reviews, and denial avoidance.
Effectively collaborate with the Interdisciplinary team including the Physician Advisor for secondary reviews.
Proactively review patients at the point of entry, prior to admission, to determine the medical necessity of a requested hospitalization and the appropriate level of care or placement for the patient.
Review surgery schedule to ensure planned surgeries are ordered in the appropriate status and that necessary authorization has been obtained as required by the payor or regulatory guidance (i.e., CMS Inpatient Only List, Payor Prior Authorization matrix, etc.)
Regularly review patients who are in the hospital in Observation status to determine if the patient is appropriate for discharge or if conversion to inpatient status is appropriate.
Proactively identify and resolve issues regarding clinical appropriateness recommendations, coverage, and potential or actual payor denials.
Maintain consistent communication and exchange of information with payors as per payor or regulatory requirements to coordinate certification of hospital services.
Coordinate and facilitate patient care progression throughout the continuum and communicate and document to support medical necessity at each level of care.
Evaluate care administered by the interdisciplinary health care team and advocate for standards of practice.
Analyze assessment data to identify potential problems and formulate goals/outcomes.
Follows the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability ACT (HIPPA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
Attend scheduled department staff meetings and/or interdepartmental meetings as appropriate.
Possesses and demonstrates technology literacy and the ability to work in multiple technology systems.
Act as a catalyst for change in the organization; respond to change with flexibility and adaptability; demonstrate the ability to work together for change.
Translate strategies into action steps; monitor progress and achieve results.
Demonstrate the confidence, drive, and ability to face and overcome challenges and obstacles to achieve organizational goals.
Demonstrate competence to perform assigned responsibilities in a manner that meets the population-specific and developmental needs of patients served by the department.
Possess negotiating skills that support the ability to interact with physicians, nursing staff, administrative staff, discharge planners, and payers.
Excellent verbal and written communication skills, knowledge of clinical protocol, normative data, and health benefit plans, particularly coverage and limitation clauses.
Must adjust to frequently changing workloads and frequent interruptions.
May be asked to work overtime or take calls.
May be asked to travel to other facilities to assist as needed.
Actively participates in Multidisciplinary/Patient Care Progression Rounds.
Escalates cases as appropriate and per policy to Physician Advisors and/or CM Director.
Documents in the medical record per regulatory and department guidelines.
May be asked to assist with special projects.
May serve as a preceptor or orienter to new associates.
Assumes responsibility for professional growth and development.
Familiarity with criteria sets including InterQual and MCG preferred.
Must have excellent verbal and written communication and ability to interact with diverse populations.
Must have critical and analytical thinking skills.
Must have demonstrated clinical competency.
Must have the ability to Multitask and to function in a stressful and fast-paced environment.
Must have working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
Must have an understanding of pre-acute and post-acute levels of care and community resources.
Must have the ability to work independently and exercise sound judgment in interactions with physicians, payors, patients, and their families.
Must have an understanding of internal and external resources and knowledge of available community resources.
Other duties as assigned.

Job Requirements:

Education/Skills

Graduate of an accredited School of Nursing OR demonstrated success in the Utilization Management Nurse I role for at least five years at CHRISTUS Health on top of required experience in lieu of education required.

Experience

Two or more years of clinical experience with at least one year in the acute care setting OR demonstrated success as Utilization Management Nurse I role at CHRISTUS Health required.

Licenses, Registrations, or Certifications

RN License in state of employment or compact required.
LPN or LVN license accepted for associates with 5+ years of demonstrated success and experience in the Utilization Management Nurse I role at CHRISTUS Health.
Certification in Case Management preferred.
BLS preferred.

Work Schedule:

8AM - 5PM Monday-Friday

Work Type:

Full Time

Apply Now

Refine Your Search

utilization management jobs in beaumont, tx

Utilization Management Nurse II - Case Management - Full Time

MDS Nurse - LVN

LTSS Service Coordinator (Hardin and Polk County)

Director, Clinical Operations

Certified Medication Aide (CMA) - Gist Unit

QMHP/Case Manager

Cancer Center Program Administrator

Provider Relations – Market Performance Lead

Licensed Professional Counselor-Associate Salary Range: $51,614 / Annually

Longshore IME & Peer Review - Audiology

Advanced Practice Provider

QMHP - Bilingual (Beaumont, Texas)

Longshore IME & Peer Review - Otolaryngology

RN

Longshore IME & Peer Review - Psychiatry

Hospital - Clinical Pharmacist Specialist (Bone Marrow Transplant)

Remote Physician (MD/DO), PMR or Neurology, Outpatient Prior Authorizations (REMOTE/FT) (IC to FTE)

Manager, Case Management & Social Work – Up to $194k + Bonus

Behavioral Health Leadership & Clinical Contract / Interim Engagements

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