Utilization Management Review Nurse

Harris Health System, Inc.; Bellaire (TX); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Harris Health System, Inc. is seeking a Utilization Management Review Nurse to evaluate medical necessity, appropriateness, and efficiency of services, ensuring care aligns with evidence-based guidelines.

The role involves partnering with Care Management, Physician Advisors, Finance, and 3rd party payers to deliver high-quality, cost-effective outcomes while supporting the health of Harris County residents.

Qualifications

• Graduated from an accredited school of Nursing with a BSN.
• Licensed to practice nursing in the State of Texas.
• 2 years in Case Management, Quality Management, Utilization Management, or Coding.

Responsibilities

• Evaluate the necessity, appropriateness, and efficiency of medical services and facilities.
• Collaborate with Care Management, Physician Advisors, Finance, and payers to ensure appropriate care.
• Reconcile denials and reconsiderations with payers; assist with appeals as needed.
• Participate in quality improvement activities and promote professional standards.

Skills

Nursing

Case Management

Utilization review

Analytical thinking

Verbal communication

Education

Bachelor of Science in Nursing (BSN)

Tools

MS Word

MS Excel

MS PowerPoint

Job description

Harris Health is the public healthcare safety-net provider established in 1966 to serve the residents of Harris County, Texas. As an essential healthcare system, Harris Health champions better health for the entire community, with a focus on low-income uninsured and underinsured patients, through acute and primary care, wellness, disease management and population health services. Ben Taub Hospital (Level 1 Trauma Center) and Lyndon B. Johnson Hospital (Level 3 Trauma Center) anchor Harris Health's robust network of 39 clinics, health centers, specialty locations and virtual (telemedicine) technology. Harris Health is among an elite list of health systems in the U.S. achieving Magnet nursing excellence designation for its hospitals, the prestigious National Committee for Quality Assurance designation for its patient-centered clinics and health centers and its strong partnership with nationally recognized physician faculty, residents and researchers from Baylor College of Medicine; McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth); and The University of Texas MD Anderson Cancer Center.

At Harris Health, we prioritize the well-being of our most valuable asset--our people--ensuring a culture of compassion, collaboration and excellence in serving Harris County's most in need. With integrity and accountability at our core, we commit to 'leading with love', embodying our dedication to quality care, education, and a steadfast respect for every individual's contribution to our mission.

Job Summary

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. This position will work with payers to reconcile denials and reconsiderations, assist with appeals as needed and arrange peer to peer level review 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 ServiceFIRST behaviors in interactions with Harris Health team members, payer vendors, and physicians.

Minimum Qualifications

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 PowerPoint

Job Attributes

Knowledge/Skills/Abilities

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

Work Schedule

• 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.

Other Special Requirements

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