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.
Registered Nurse; minimum of five (5) years clinical experience; BSN preferred.
2 years' experience with Private Duty Nursing and/or Personal Care Services required
Experience with medically fragile populations preferred
Bilingual preferred, but not required
Strong skills in the following areas: Oral and written communication; Critical thinking; Organization and time management; Customer service.
Current, unrestricted Registered Nurse license in the state of Texas required.