RN - Children's Health System of Texas (CHST) Utilization Management Nurse Job

Children's Health - Managed Care Careers

Job Number: GRP20181602-05887

Location: Dallas, TX

Date Posted: 5-30-2018


Position Summary

The Utilization Management Nurse is responsible for determining and managing medical necessity of acute inpatient admissions utilizing clinical criteria. This includes communication with the Physician's admitting patients to a Children's Health System of Texas (CHST) facility and collaboration with the Physician Advisor during the review process.

Essential Duties and Responsibilities


  • Requires in-depth professional knowledge and practical/applied expertise in own discipline and basic knowledge of related disciplines within the broader professional field
  • Has knowledge of best practices and how own area integrates with others; demonstrates awareness of the industry, including regulatory, evolving customer demands, and the factors that differentiate the organization in the market
  • Acts as a resource for colleagues with less experience; may lead projects with manageable risks and resource requirements
  • Solves complex problems and takes a new perspective on existing solutions; exercises judgment based on the analysis of multiple sources of information
  • Impacts a range of customer, operational, project or service activities within own team and other related teams; works within broad guidelines and policies
  • Works independently, receives minimal guidance
  • Explains difficult or sensitive information; works to build consensus
  • Performs initial review of acute care patients utilizing medical necessity criteria, CHST clinical pathways, and clinical knowledge to determine appropriate level of care within 12 hours of admission.
  • Performs concurrent review of all patients admitted for an observation period to determine appropriate level of care daily
  • Performs discharge review of all patients discharged within 72 hours of inpatient admission
  • Combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided.
  • Through continuous assessments, problem identification and education facilitates the quality of health care delivery in the most cost effective manner.
  • Leverages clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness.
  • Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health-care facility to comply with government and insurance company reimbursement policies: Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.
  • Maintains a level of productivity and quality consistent with: complexity of the assignment; facility policies and guidelines; established principles, ethics and standards of practice of professional nursing;
  • Other job duties as assigned


  • Four-year Bachelor's degree or equivalent experience, required

Licenses & certifications

  • Registered Nurse, required
  • Accredited Case Manager (ACM) or Certified Case Manager (CCM) certification, preferred


  • Five (5) years clinical nursing (pediatrics preferred), required
  • Minimum 1 year Utilization Review or Case Management experience, required
  • Appeals experience, preferred
  • Previous experience with Interqual or Milliman, preferred

Specific knowledge, skills, and abilities

  • Effectively keyboard at least 55 words per minute
  • Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
  • Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
  • Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
  • Develop and use collaborative relationships to facilitate the accomplishment of work goals.
  • Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
  • Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
  • Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
  • Effectively manage one's time and resources to ensure that work is completed efficiently.
  • Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
  • Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self impose standards of excellence rather than having standards imposed.
  • Assimilate and apply new job-related information in a timely manner.
  • Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message. CB#

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