Utilization Management RN - Clinical Review - Weekend PRN

Utilization Management RN - Clinical Review - Weekend PRN

Bring your passion to THR so we are Better + Together!!

Work location:

Remote

Work hours:

PRN Weekends from 6:45a - 3:15p with some holiday requirements. Must be available to train for 4-6 weeks during the week then transition to weekends

• Remote work
• Collaborative community impact
• Team based environment

• Associate's degree in Nursing required
• Bachelors degree in Nursing preferred
• 5 years inpatient clinical nursing experience in an acute hospital setting required and
• 1 Year Utilization Management experience
• case management and/or the application of medical necessity criteria preferred
• Texas RN upon hire required
• case management certification within 12 months of hire preferred
• MCG certification within 12 months of hire preferred

• 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.
• Provide consultation to medical and nursing staff, health information management, and payers on potential issues with reimbursement of hospitalization.
• Partner with hospital care transitions managers to assure effective hand-off of information related to the plan of care.
• Work with bedside nurses and care team members to assure orders related to status are accurate and valid. Refer cases to physician advisor for review and determination of status or care needs.
• Evaluate concurrent potential denials or payment issues and initiate communication with admitting physician to assure proper documentation for selected admission status.
• Initiate and facilitate physician communication relative to the UR process when indicated. Assist and facilitate the physician peer-to-peer review process with insurance medical directors as indicated.
• Determine working DRG with each initial review via CareConnect1 or other Utilization Management tool. Discusses working DRG issues as needed with Care Transition Manager.
• 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.

• Benefits include 401k, PTO, medical, dental, Paid Parental Leave, flex spending, tuition reimbursement, Student Loan Repayment Program as well as several other benefits.
• At Texas Health, our people make this a great place to work every day. Our inclusive, supportive, people-first, excellence-driven culture make Texas Health a great place to work.
• A supportive, team environment with outstanding opportunities for growth.

We invite you to join us in furthering your career through our accomplishments and philosophy of excellence.

Texas Health requires a resume when an application is submitted. Employment opportunities are only reflective of wholly owned Texas Health Resources entities.

We are an Equal Opportunity Employer and do not discriminate against any employees or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.