Utilization Review Nurse at El Paso Childrens Hospital Corporation El Paso, TX

Responsibilities

Monitor adherence to the hospital’s utilization review plan to ensure effective and efficient use of hospital services. Ensure the appropriateness of hospital admissions and extended stays. Integrate clinical knowledge with billing knowledge to review, evaluate, and arrange peer-to-peer reviews when clinical denials related to medical necessity arise while the patient is hospitalized. Work closely with physician advisers to support policy development and process improvement.

• Two (2) years prior experience with Utilization Management.
• Previous training and demonstrated competence in negotiations, quality assurance, case management outcomes, and keyboarding/computer use.
• Experience with Inter Qual and/or Milliman Care Guidelines.
• Strong organizational and time management skills.
• Ability to work on extremely complex problems where analysis of situation or data requires evaluation of intangible variance factors.
• Current RN License to practice in the State of Texas.
• Associate’s Degree in Nursing; BSN preferred.
• Proficient verbal, written, and interpersonal communication skills.
• Knowledge of managed care, reimbursement and utilization management.
• Knowledge of ICD-10, DRGs, and medical necessity criteria.
• Knowledge of claims denials and appeals processing.
• Ability to coordinate and manage multiple priorities and projects simultaneously, reprioritizing as necessary.
• Self-motivation, multi-tasking, and prioritizing in a fast-paced environment.
• Analytical and problem-solving skills.
• Knowledge of HIPAA standards.
• Knowledge of various insurance plan coverages for Home Health, DME, SNF, LTAC agencies.
• Ability to operate standard office equipment, basic computer, word-processing, and spreadsheet skills (Microsoft).
• Strong customer service orientation and ability to work with people of all backgrounds.
• Knowledgeable regarding community resources.
• Knowledge of English grammar, punctuation, and spelling.