Utilization Management Review Nurse

About Us

Harris Health is the public healthcare safety-net provider established in 1966 to serve the residents of Harris County, Texas. As an essential healthcare system, Harris Health champions better health for the entire community, with a focus on low-income uninsured and underinsured patients, through acute and primary care, wellness, disease management and population health services. Ben Taub Hospital (Level 1 Trauma Center) and Lyndon B. Johnson Hospital (Level 3 Trauma Center) anchor Harris Health's robust network of 39 clinics, health centers, specialty locations and virtual (telemedicine) technology. Harris Health is among an elite list of health systems in the U.S. achieving Magnet® nursing excellence designation for its hospitals, the prestigious National Committee for Quality Assurance designation for its patient-centered clinics and health centers, and its strong partnership with nationally recognized physician faculty, residents and researchers from Baylor College of Medicine; McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth); and The University of Texas MD Anderson Cancer Center.

At Harris Health, we prioritize the well-being of our most valuable asset—our people—ensuring a culture of compassion, collaboration and excellence in serving Harris County's most in need. With integrity and accountability at our core, we commit to 'leading with love', embodying our dedication to quality care, education, and a steadfast respect for every individual's contribution to our mission.

About the Role

The Utilization Management Review Nurse (UMRN) performs technical and administrative work required to evaluate the necessity, appropriateness, and efficiency of the utilization of medical services procedures and facilities. This role supports the health system by utilizing clinical knowledge, expertise, and industry standard clinical guidelines, carrying the responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. The UMRN promotes quality care and cost-effective outcomes to enhance the physical, psychosocial, and vocational health of individuals, partnering with Care Management, Physician Advisors, Finance, and 3rd party payers to deliver the best holistic outcomes for all patients.

This position will work with payers to reconcile denials and reconsiderations, assist with appeals as needed, and arrange peer-to-peer level review while collecting, analyzing, and addressing variances from the plan of care/care path with physicians and/or other members of the healthcare team. The UMRN participates in quality improvement activities, exemplifies professionalism, and promotes a customer-friendly environment by utilizing ServiceFIRST behaviors in interactions with Harris Health team members, payer vendors, and physicians.

Responsibilities

• Evaluate the necessity, appropriateness, and efficiency of medical services, procedures, and facilities.
• Ensure care is provided at the appropriate level based on medical necessity using clinical guidelines.
• Promote quality care and cost-effective outcomes for patients.
• Partner with Care Management, Physician Advisors, Finance, and third-party payers to optimize patient outcomes.
• Reconcile denials and reconsiderations with payers, assist with appeals, and arrange peer-to-peer reviews.
• Collect, analyze, and address variances from the plan of care/care path with physicians and healthcare teams.
• Participate in quality improvement activities.
• Exemplify professionalism and promote a customer-friendly environment using ServiceFIRST behaviors.

Requirements

• Graduated from an accredited school of Nursing with a Bachelor's in Nursing.
• Registered Nurse: Licensed to practice nursing in the State of Texas.
• Case Management Certification (ACM or CCM) within two years of hire.
• Basic Life Support: American Heart Association (AHA) or Red Cross approved program.
• 5 years of experience: Strong clinical background in a variety of acute healthcare settings, including 2 years in Case Management, Quality Management, Utilization Management, or Coding.

Skills

• Above Average Verbal Communication (Heavy Public Contact).
• Exceptional Verbal (Public Speaking).
• Writing/Correspondence and Writing/Reports.
• Bilingual Skills (Preferred).
• Proficiency in MS Word, MS Excel, and MS PowerPoint.
• Analytical and mathematical skills.
• Knowledge of medical terms and utilization review tools: MCG and/or Change Healthcare (Interqual).

Schedule

• Flexible: 8-hour shifts as per system need; variable to 10-12 hours as needed.
• Weekends: Depends on needs of the system.
• Holidays: Depends on needs of the system.
• Telecommute options available.

Other Special Requirements

Equipment Operated: Standard office equipment, computer software, etc.