Responsible for the coordination and efficient utilization of health care resources, including Private Duty Nursing (PDN) and Personal Care Services (PCS) for Cook Children's Health Plan (CCHP) members. Works with the Department Managers and Supervisors to assure the timely provision of quality care throughout the continuum of care.The Registered Nurse Utilization Management RN Private Duty Nursing and Personal Care Services (UM RN PDN/PCS) facilitates clinically appropriate and fiscally responsible care through communication with the care management team, providers and health plan medical directors.The UM RN PDN/PCS Reviewer assesses and identifies the member's clinical information and determines, in conjunction with the Medical Director, medical necessity and appropriateness of requested services. Utilizes Medical Management Committee (MMC) approved clinical criteria to authorize requested services for the member. The UM RN PDN/PCS Reviewer communicates with providers of care/services to facilitate appropriate care transitions. The UM RN PDN/PCS Reviewer assures adherence to regulatory/contractually required timeliness standards for authorization request processing, associated communications and notice of adverse determinations are met for CCHP. Acts as the subject matter expert on Private Duty Nursing and Personal Care Services and assists Service Coordinators, Case Managers, and Utilization Management Reviewers with determinations for these services. Performs UM review and authorization of PDN and PCS to assist the team.
Bachelor of Science in Nursing required, Master's degree preferred.
Health plan utilization management experience preferred.
5-8 years' experience with Private Duty Nursing and Personal Care Services.
Experience with medically fragile populations required.
Bilingual preferred but not required.
Strong skills in the following areas:
Oral and written communication
Organization and time management
Licensure, Registration, and/or Certification
Current, unrestricted Registered Nurse license in the state of Texas required.
Cook Children's Health Care System is a not-for-profit, nationally recognized pediatric health care organization comprised of eight entities – a Medical Center, Physician Network, Home Health company, Northeast Hospital, Pediatric Surgery Center, Health Plan, Health Services Inc., and Health Foundation.Cook Children's Medical Center Based in Fort Worth, Texas, the integrated system has more than 6...0 primary and specialty care offices throughout North Texas. Its service region includes Denton, Hood, Johnson, Parker, Tarrant and Wise counties, with an additional referral area encompassing nearly half the state.Cook Children's traces its roots back to 1918, but throughout its continual change and robust growth, it still embraces an inspiring promise – to improve the health of every child in its region through the prevention and treatment of illness, disease and injury. To live up to this promise, Cook Children's combines the art of caring with the use of leading technology and extraordinary collaboration to provide exceptional care for every child, every day.History – Cook Children's has a rich history of nearly a century of caring for children.Our Promise – Knowing that every child's life is sacred, it is the promise of Cook Children's to improve the health of every child in our region through the prevention and treatment of illness, disease and injury.Companies – Based in Fort Worth, Texas, Cook Children's is a not-for-profit organization that is comprised of eight nationally recognized companies.Community Health Outreach – Cook Children's Community Health Outreach works together with over 150 partner organizations to improve the safety and health of at-risk children through education, disease and injury prevention and support.Clinical Research – Cook Children's is home to a skilled team of research-minded physicians, nurses and health care professionals and administrators who drive our commitment to excellent clinical care and the search for medical advances.Public Relations – Cook Children's Public Relations works with national and local media outlets, produces Cook Children's publications, coordinates special events and helps develop key relationships within the community.Contractor & Vendor Information – Cook Children's contractors and vendors must ensure their employees are knowledgeable about working with our organization.Sponsorship guidelines – Cook Children's sponsors a select number of events that are strongly aligned with its promise to improve the health of every child in the region through the prevention and treatment of illness, disease and injury.