Registered Nurse (RN) - Utilization Review

Baptist Health System; San Antonio (TX); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Health insurance

Dental

Vision

401(k)

Paid time off

Career development

HSAs & FSAs

EAP

Pet insurance

Job summary

Baptist Health System is seeking a Registered Nurse to coordinate patient care resources and ensure appropriate utilization of services. The role emphasizes medical necessity, payer negotiations, and adherence to Tenet standards.

Required RN licensure with 2 years of acute care experience; ACM preferred. You will complete InterQual training within 30 days of hire and demonstrate proficiency with Tenet Case Management systems.

Qualifications

• Graduate of an accredited School of Nursing.
• Bachelor's or Master's in Nursing preferred.
• Minimum 2 years acute hospital or behavioral health patient care experience with at least 1 year utilization review in an acute hospital or commercial/managed care payer setting.
• Accredited Case Management (ACM) certification preferred.
• Must complete Tenet’s InterQual education course within 30 days of hire and pass with a score of 85 or better. Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire.

Responsibilities

• Facilitate effective resource coordination to help patients achieve optimal health and appropriate utilization of resources.
• Manage medical necessity process for accurate and timely payment for services; may require payer negotiation on a case-by-case basis.
• Support utilization management services to ensure medical necessity and denial prevention.
• Coordinate with payers to authorize appropriate level of care and length of stay for medically necessary services.
• Educate payers, physicians, hospital staff and ancillary departments about covered services and administration of benefits.

Job description

Overview

Join our dedicated healthcare team where compassion meets innovation! As a Registered Nurse with us, you'll have the opportunity to make a meaningful impact in patients' lives while enjoying a supportive work environment that fosters professional growth and work-life balance. Ready to be a vital part of our mission?

At Baptist Health System, We Understand That Our Greatest Asset Is Our Dedicated Team Of Professionals. That’s Why We Offer More Than a Job – We Provide a Comprehensive Benefit Package That Prioritizes Your Health, Professional Development, And Work-life Balance. The Available Plans And Programs Include

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Note: Eligibility for benefits may vary by location and is determined by employment status

Job Summary

The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case-by-case basis. This position integrates national standards for case management scope of services including:

• Utilization Management services supporting medical necessity and denial prevention
• Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient
• Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
• Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits
• Other related duties as assigned

Qualifications

MINIMUM EDUCATION: Graduate of an accredited School of Nursing

PREFERRED EDUCATION: Bachelors or Masters Degree in Nursing

MINIMUM EXPERIENCE: 2 years acute hospital or behavioral health patient care experience with at least 1 year utilization review in an acute hospital or commercial/managed care payer setting.

PREFERRED EXPERIENCE: Previous Case Management Supervisory experience.

REQUIRED CERTIFICATIONS/LICENSURE: Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN license for state(s) covered.

PREFERRED CERTIFICATIONS/LICENSURE: Accredited Case Management (ACM)

REQUIRED COURSES/ COMPLETIONS: Must complete Tenet’s InterQual® education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better. Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire. Orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQual®, Utilization Management, and other topics specific to case management.

Organization Description

Baptist Health System has more than 120 years history of caring for our community and making a positive difference. Our system of care includes six full-service hospitals, a specialized childrens hospital with a dedicated pediatric emergency unit, a comprehensive cancer care network, fitness and rehabilitation centers, a physician network, imaging centers, ambulatory services and the Baptist School of Health Professions. Wherever you go in the Baptist Health System, youll find that we have the same goal to help people achieve health for life through compassionate service inspired by faith. Join our team!

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.

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