RN/Registered Nurse-Utilization Management, Clinical Reviews

Fast-paced, high volume reviews and denials department is looking for top skilled UM Nurse. Is that you?

Work location: 100% remote but must live in the Dallas-Fort Worth area.

Work hours: Full time, 40 hours

Department highlights:

• Flexible schedule
• Remote work environment
• Collaborative team approach

Here’s What You Need

Education
Associate's Degree Nursing Required Or
Bachelor's Degree Nursing Preferred

Experience
5 Years Inpatient clinical nursing experience in an acute hospital setting Required and
1 Year Utilization Management Required and
Experience in case management, and/or the application of medical necessity criteria Preferred

What You Will Do

• Responsible for determining initial admission status and level of care recommendations for inpatient admissions, observation and outpatient admissions for any hospital in the THR system (requires access to all facilities in Care Connect)
• Conduct initial admission review of inpatient, observation and outpatient admissions (commercial insurance, Medicare Advantage and self-pay) according to established criteria set adopted by System. Conduct initial admission review of inpatient, observation and outpatient admissions with traditional Medicare for compliance with the New IPPS rule.
• Provide clinical information to payors as needed for completion of pre-certification process.
• Ensure proper authorization requirements are met with each admission. Obtains or ensures acquisition of appropriate pre-certifications/authorizations from third party payers and placement to appropriate level of care prior to hospitalization or upon admission utilizing medical necessity criteria and third party payer guidelines.

• Obtain or facilitate acquisition of urgent/emergent authorizations, continued stay authorizations, as needed and with compliance with all regulatory and contractual requirements.

• Maintains a working knowledge of care management, utilization review changes, authorization changes, contract changes, regulatory requirements, etc.
• Communicate and collaborate with the CBO and medical records to render appropriate information needed to secure reimbursement.
• Provide consultation to medical and nursing staff, health information management, and payers on potential issues with reimbursement of hospitalization.
• Evaluate concurrent potential denials or payment issues and initiate communication with admitting physician to assure proper documentation for selected admission status.
• Communicate payer issues and medical necessity concerns with members of the health care team.
• Partner with hospital care transition managers to assure effective hand-off of information related to the plan of care.
• Cover multiple THR sites adjusting practice to meet the requirements of each location.

Additional perks of being a Texas Health Employee

• Delivery of high quality of patient care through education, research, and innovations in practice.
• Strong Unit Based Council (UBC).
• A supportive, team environment with outstanding opportunities for growth.
• Explore our Texas Health careers site for info like Benefits, Job Listings by Category, recent Awards we’ve won and more.

Do you still have questions or concerns? Feel free to email your questions to recruitment@texashealth.org

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