Utilization Review Specialist Nurse; RN | Case Management

FLSA STATUS

Exempt

• Bachelor’s degree or higher from an accredited school of Nursing
• Master’s degree preferred

• Five years of hospital clinical nursing experience, which includes three years in utilization review and/or case management

• RN - Registered Nurse - Texas State Licensure - Texas Board of  Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)
• Magnet ANCC-recognized Case Management certification: ACHPN-HPCC or CCM or CMC or ACM-NBCM or CDCES or CHPN-HPCC or CMGT-BC or CM-ABOHN or CMCN or ANCC-NCM

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations
• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
• Expert knowledge of Inter Qual Level of Care Criteria or Milliman Care Guidelines and knowledge of local and national coverage determinations
• Comprehensive knowledge of Medicare, Medicaid, and Managed Care requirements
• Comprehensive knowledge of community resources, health care financial and payer requirements/issues, and eligibility for state, local, and federal programs
• Comprehensive knowledge of utilization management, case management, performance improvement, and managed care reimbursement
• Ability to work independently and exercise sound judgment in interactions with physicians, payers, and health care team members
• Strong assessment, organizational, and problem-solving skills
• Maintains level of professional contributions as defined in Career Path program
• Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44)
• Competent computer skills of the entire Microsoft Office Suite (Access, Excel, Outlook, PowerPoint, and Word

• Collaborates with the physician and all members of the interprofessional health care team to facilitate care and communication with payers, and external case managers. Intervenes, as necessary, to ensure the plan of care and services provided are patient-focused, high-quality, efficient, and cost-effective. Serves as a preceptor and implements staff education specific to patient populations and unit processes, coaches and mentors other staff and students.
• Serves as a resource for the department and hospital. Provides education to physicians, nurses, and other health care providers on utilization management topics.
• Initiates improvement of department scores for employee engagement, i.e., peer-to-peer accountability.

• Performs review for medical necessity of admission, continued stay, and resource use, appropriate level of care and program compliance. Identifies when services no longer meet evidence-based criteria, initiates discussions with attending physicians, coordinates with external utilization review teams to facilitate efficient use of resources and seeks assistance from the Physician Advisor when necessary. Informs management of the possible need for issuing Medical Hospital Issued Notices of Non-Coverage and Advance Beneficiary Notices of Non-Coverage.
• Applies approved utilization criteria to monitor appropriateness of admissions, level of care, resource utilization, and continued stay. Reviews level of care denials to identify trends and collaborates with team to recommend opportunities for process improvement.
• Promotes medical documentation that accurately reflects intensity of services, quality and safety indicators and patient’s need to continue stay. Identifies potentially unnecessary services and care…