TempleRecruiter
the smart solution for Temple jobs

Health Plan Utilization Management RN

Company: Baylor Scott White Health
Location: Temple
Posted on: September 14, 2018

Job Description:

Job Description

Health Plan Utilization Management RN

Preferred Qualifications

The UM Nurse performs utilization management, utilization review, and/or concurrent review for the Scott & White Health Plan's (SWHP) Leading Change Care Coordination Team. The UM Nurse reviews cases using standard, specific guidelines and algorithms to process assigned events. The UM Nurse determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines. The UM Nurse manages the utilization functions within the following areas: Contracted (nuclides DRG), DME and HH, and outpatient approvals and denials.
The UM Nurse performs functions related to standard cases for utilization management, utilization review, and/or concurrent review, including: (1) assessing, interpreting, and responding to customer needs or requirements; (2) identifying solutions to non-standard requests and problems; (3) transforming concepts into practice keeping the member at the center of decision making, and (4) determining medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines (InterQual, SWHP Medical Policy, CMS criteria, etc.) and benefit determination. The UM Nurse completes comprehensive documentation as outlined in policies, standard operating procedures, job aids, and workflows. The UM Nurse identifies, documents and communicates potential quality assurance/ risk management issues to the appropriate entity/department manager, directors, AVP and/or the QI committee as instructed ensuring member/provider needs are met. The UM Nurse participates in process improvement projects to continuously enrich care coordination efforts and ensure evidenced based processes are utilized. The UM Nurse clearly communicates Population Management policy decisions and changes to other departments and Divisions. The UM Nurse acts as a consultant to staff and Plan members in responding appropriately to inquiries and providing clarification on Population Management policies
The ideal candidate for the UM Nurse role will have broad medical-surgical experience. The ideal candidate for the UM Nurse role will maintain current knowledge on available resources within the system and readily shares that information with other health care professionals, staff members, SWHP/ICSW members and their families. The ideal candidate for the UM Nurse role will also be able to understand and implement TDI, CMS, DOL, HHSC and NCQA standards and requirements.

Location/Facility - Health Plan
For more information on the facility, please click our Locations link.

Specialty/Department/Practice - Nursing

Shift/Schedule - Full Time Days

Benefits - Our competitive benefits package includes*:

Immediate eligibility for health and welfare benefits

401(k) savings plan with dollar-for-dollar match up to 5%

Tuition Reimbursement

PTO accrual beginning Day 1



*Note: Benefits may vary based upon position type and/or level.

Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation's exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it's accepting a calling!

H.S. Diploma/GED Equivalent

3+ Years Experience

RN or LVN License


United States
S&W Health Plan - West Campus (11042)
1206 W Campus Dr
Temple, 76502

NursesInsurance

Keywords: Baylor Scott White Health, Temple , Health Plan Utilization Management RN, Healthcare , Temple, Texas

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Other Healthcare Jobs


Healthcare Licensed Insurance Agent - Work From Home (Cedar Park,TX)
Description: Join us at TTEC Home where we welcome Healthcare Licensed Insurance Agents who have a passion for helping others and giving them peace of mind. Whether its getting answers
Company: TTEC
Location: Cedar Park
Posted on: 09/24/2018

Associate Chair of Clinical Innovation
Description: Academic/Faculty/Research opening in Austin, Texas. This and other physician jobs brought to you by DocCafe.com Job Description Requirements br Associate Chair of Clinical Innovation in Texas br (more...)
Company: Merritt Hawkins
Location: Austin
Posted on: 09/24/2018

Pulmonary Medicine Physician General & Critical Care Pulmonologist - Physicians Only Apply - Perm
Description: A Pulmonary Medicine Physician General Critical Care Pulmonologist practice is seeking a qualified physician for AUSTIN, TX. This and other physician jobs brought to you by ExactMD. Medical Doctors (more...)
Company: UnitedHealth Group
Location: Austin
Posted on: 09/24/2018


Healthcare Specialist
Description: Our nationwide company has expanded and we are currently interviewing people to fill PT and FT healthcare benefit enrollment positions. As a Benefit Consultant, you can help people save money on their (more...)
Company: TQS
Location: Manchaca
Posted on: 09/26/2018

RN Resident (Registered Nurse) - Clinical Decision Unit (CDU) (February Cohort)
Description: With more than 110 sites across Central Texas, St. Davids HealthCare includes seven of the areas leading hospitals and is one of the largest health systems in Texas. The organization was recognized with (more...)
Company: South Austin Medical Center HCA Healthcare
Location: Austin
Posted on: 09/24/2018

Registered Nurse (RN) - Critical Care - Float Pool - Nights
Description: St. David's North Austin Medical Center is part of St. David's HealthCare, one of the largest health systems in Texas, which was recognized with a Malcolm Baldrige National Quality Award in 2014. The (more...)
Company: North Austin Medical Center
Location: Austin
Posted on: 09/26/2018

1000 Weekly As a HealthCare REP. INTERVIEWING THIS WEEK
Description: We are currently Hiring customer services and health benefits reps who can
Company: Jumpstart consult
Location: Austin
Posted on: 09/26/2018

RN Registered Nurse - Medical Surgical - Med Surg - (Sign on
Description: Job ID: 274369 RN Registered Nurse - Medical Surgical - Med Surg - Sign on bonus available Burnet, Texas Regular / Day Additional Job Information Title:--RN-Registered NurseCity, State:-- Burnet,TXLocation:-- (more...)
Company: Seton Family of Hospitals, TX
Location: Burnet
Posted on: 09/24/2018

Nurse Practitioner - AFIB
Description: With more than 110 sites across Central Texas, St. David's HealthCare includes seven of the area's leading hospitals and is one of the largest health systems in Texas. The organization was recognized (more...)
Company: St. David's HealthCare
Location: Austin
Posted on: 09/24/2018

RN Pediatric Registered Nurse -Float
Description: Job ID: 259724 RN Pediatric Registered Nurse -Float Austin, Texas Regular Additional Job Information Title:--RN-FloatCity, State:-- Austin,TXLocation:-- Chevy Chase BldgDepartment:---- Nurse Staffing (more...)
Company: Seton Family of Hospitals, TX
Location: Austin
Posted on: 09/26/2018

Log In or Create An Account


Find us on Facebook

Find us on LinkedIn

Get the latest Texas jobs by following @recnetTX on Twitter!

Temple RSS job feeds