Utilization Review Coordinator  
 
Can be fully Remote but prefer candidates local to Houston.  
 
Shift: Can start as early as 7am- 6pm (shifts will be staggered 7a-4p, 8a-5p, or 9a-6p) - **Will need 3 Coordinators who can work on weekends (Weekend hours are 7am-4pm or 8am-5pm- if work on weekends- will have 2 days off during the week) 
 
Interviews: Teams with Karen DeJean and Celeste Green 
 
MINIMUM QUALIFICATIONS: 
LVN, current Texas License or current in a National Licensure Compact participating state). 
Three years clinical experience in managed care organization 
Two years working in UR, working within applicable state, federal, and third-party regulatory agencies i.e., CMS, HHSC, TDI and Medicaid/Medicare population experience 
Highlight lines of business worked- Texas Medicaid, CHIP, marketplace 
Highlight experience - was it inpatient or outpatient  
Microsoft Office (Word, Outlook, Excel) 
 
WIll need to use their OWN EQUIPMENT: 2 screens, will need a headset, high speed internet, (Chromebooks do not work well but MAC or any other seem to work fine) 
 
 
1.         Provide support in the development and generation of the UM adverse determination letters. 
2.         Review of adverse determination letters for accuracy and appropriateness of Medical Director documentation to ensure compliance to all regulatory requirements prior to mailings. 
3.         Monitor letter generation and mailing accuracy of all adverse determination letters to ensure compliance 
4.         Accurately enters the required information into the managed care platform, adhering to UM policies and procedures. 
5.         Telephonic outreach to providers to obtain additional information as directed by the Medical Director 
6.         Makes appropriate referrals and follow up to other Community programs/departments as directed by the Medical Director 
7.         Meets required performance metrics for cases reviewed within established turnaround times. 
8.         Meets established quality standards 
9.         Actively contributes to achievement of departmental goals, as identified in Department’s annual business plan, including specific departmental process improvement plans. 
10.       Demonstrates Harris Health and Community Health Choice values, including trust, integrity, mutual respect, diversity, responsiveness, and caring service. 
11.       Other duties as assigned. 
 
 
 
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			<td style="border-style: none;border-width: 6.0pt;height: 74.45pt;padding: 0.0in 5.4pt 0.0in 5.4pt;width: 456.9pt;" valign="top" width="609"> JOB SUMMARThe UM LVN works closely with Medical Directors to ensure compliance by assisting in the management of the UM adverse determination letter generation process.  The UM LVN utilizes nursing knowledge, critical thinking, and experience to review these letters to ensure appropriate documentation and citation of regulatory requirements are referenced in letters to members and/or providers.  This position works closely with Medical Directors to follow-up and work with providers to obtain necessary information in of support of rendering an UM determination and for updating and modifying approved and denied authorizations based on the Medical Director decision when required. </td>
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Right to Hire - Prior Auth/Referrals

$20 - $23/hr

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