PRN Utilization Management Review Nurse

Job Number: 178949,

Job Title:

PRN Utilization Management Review Nurse, Salary: $47.37 - $57.80

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.

The UMRN works with payers to reconcile denials and reconsiderations, assists with appeals as needed, and arranges peer-to-peer level reviews while collecting, analyzing, and addressing variances from the plan of care/care path with physician 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 Service

FIRST behaviors in interactions with Harris Health team members, payer vendors, and physicians.

• Degrees:
  Graduated from an accredited school of Nursing with a Bachelors in Nursing.
• Licenses &
  
  Certifications:
  • 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.
• Work Experience:
  • 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.
• Communication
  
  Skills:
  • Above Average Verbal Communication (Heavy Public Contact)
  • Exceptional Verbal (Public Speaking)
  • Writing/Correspondence
  • Writing/Reports
• Language:
  • Bilingual Skills (Preferred)
• Proficiencies:
  • MS Word
  • PC
  • MS Excel
  • MS Power Point

• Analytical
• Mathematics
• Medical Terms
• Utilization review tools: MCG and/or Change healthcare (Interqual)

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

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