Utilization Review Nurse

About the role

Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations and documentation requirements.

Responsibilities

• Collaborates with the Central Scheduling Department (CSD) team to provide accurate and complete clinical information in order to obtain authorization.
• Conducts admission reviews for Medicare and Medicaid beneficiaries as well as private insurance members and self-pay patients utilizing evidence-based guidelines.
• New admission reviews are done concurrently at the point of entry when the admission order is placed and necessary clinical information is available in the medical record.
• Communicate with admitting physicians and physician advisors when documentation does not appear to support hospital level of care.
• Use hospital approved medical necessity tool to determine level of care for inpatient or observation/outpatient services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two-midnight stay.
• Keeps current on all Federal, State and local regulatory changes that affect delivery or reimbursement of acute care services within the scope of Utilization Management.
• Uses knowledge of national and local coverage determinations to appropriately advise physicians.
• Proactively collaborates with admitting physician to provide accurate level of care determination at the time of review.
• Escalates identified progression-of-care/patient flow barriers to appropriate departments.
• Actively participates in daily huddles, departmental meetings and education offerings.
• Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes.
• Educates members of the patient's care team on the appropriate access to and use of various levels of care.
• Promotes use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care.
• Serves as a resource person to physicians, care coordinators, physician offices and billing office for coverage and compliance issues.
• Completes all reviews within department established policies and best practice standards. Meets department quality standards as established for the department, i.e.: Inter-rater Reliability audits, completing all initial reviews within established time frames, completes concurrent and discharge reviews to meet department and industry standards.
• Performs other duties as assigned.

Requirements

• Education: Graduate of accredited nursing program and holds an active unrestricted RN license in the State of Texas.
• Experience: 5 years experience to include 2 years of clinical experience and minimum of 3 years of recent utilization review experience.
• Prior experience with Epic CCM.
• Licenses and Certifications: (RN) REGISTERED NURSE holds an active unrestricted RN license in the State of Texas.

Qualifications

• Acute care experience preferred.

Skills

• Actively participates in the department's performance improvement initiatives.
• Basic computer skills and knowledge.
• Expert knowledge of hospital approved, evidence based medical necessity tool and knowledge of local and national coverage determinations.
• Identifies avoidable days (quality and risk issues), makes appropriate referrals. Confers with Manager and/or Medical Director as appropriate.
• Identifies the need for professional growth and seeks out appropriate development opportunities.
• Evaluates outcomes data to identify trends and areas for improvement (i.e. avoidable days, denial information).
• General good health and stress coping ability.
• Ability to speak and hear, to allow discussions with physicians, patients, and other members of the healthcare team.
• Possess near vision acuity for accurate reading of computer screens and recording on patient charts.

Benefits

• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100% coverage for preventive healthcare — no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer

Schedule

Thursday – Sunday; four 10-hour day shifts. Full-time, day shift.

Physical requirements and working conditions

• Physical Requirements: Talking
• Working Conditions: Office Setting

Primary location: 5323 Harry Hines Blvd, Dallas, Texas. Regular employee status, individual contributor level.