TIHP Utilization Management Nurse (84124)

Primary ResponsibilitiesThe Utilization Management Nurse will determine the medical appropriateness of inpatient and outpatient services by evaluating medical guidelines, benefit determination and compliance with state mandated regulations.Essential Functions• Perform concurrent, retroactive and pre-service authorization reviews for inpatient and outpatient services.• Follow and maintain compliance with CMS requirements, may include after-hours, holiday and weekend coverage.• Collaborate with staff, physicians, care/service coordinators, and medical directors to coordinate and provide the level of care necessary to meet member's health need.Educational/Training RequirementsGraduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred. 2+ years of clinical nursing experience.Payor Utilization Management: 3 years recommended experienceProficiency with Microsoft Office applications, specifically Word, Excel, and OutlookProficiency using Milliman Care Guidelines (MCG) and/ or InterQual criteria.Licensing RequirementsCurrent unencumbered LVN or RN license in Texas or compact license.Experience Requirements2+ years Utilization management experience with a health insurance company (managed care/payer experience required).UM for Medicare Advantage, Managed Medicaid, Dual SNP Lines of Business, on the payer side.5+ years of acute clinical experience.The ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families.Physical Demands