Utilization Review Nurse

Pacer Group; Austin (TX); Sur place; USD 48 000 - 68 000; Plein temps

Avantages offerts par ce poste

Medical

Dental

Vision

401(K)

Résumé du poste

Pacer Group in Austin, TX seeks a qualified Utilization Management RN to join our centralized UM team across acute care facilities. The role centers on admissions, discharge planning, and utilization review in a fast-paced setting.

Responsibilities include reviewing medical necessity for prospective, concurrent, and retrospective requests, navigating CMS regulations and InterQual/MCG criteria, and assisting with coding, documentation, and payer communications.

Qualifications

• Licensed RN with multi-state or TX license required.
• At least 2 years acute care UM experience or equivalent.
• Proficient with InterQual, MCG, and CMS regulations.
• Experience with payer portals and managed Medicare/Medicaid preferred.
• Familiarity with Google Workspace; remote work experience a plus.

Responsabilités

• Provides admissions, case management, discharge planning and utilization review.
• Reviews admissions and service requests for medical necessity and reimbursement policy.
• Assists coding, medical records/documentation, precertification, reimbursement, and denials/appeals.
• Coordinates discharge planning with the healthcare team.
• May prepare utilization review reports as necessary.
• Oversees compliance with payer utilization management rules and regulations.

Connaissances

Licensed RN

Utilization Management

InterQual/MCG

CMS regulations

Remote work experience

Formation

RN license (multistate or TX)

Outils

Cerner

Careport (Allscripts)

Google Workspace

Description du poste

Schedule: Monday to Friday (08:30 - 17:00).

Pay Rate: $42/hr.

POSITION OVERVIEW:

• High-level overview of the department: Centralized acute admission utilization review across 13 acute care and critical access hospitals
• What type of unit: Utilization Management
• Number of beds on the unit: NA
• Ancillary staff and charge: Utilization Management Assistant, UM Managers: Pam Long, Jennifer Liles
• What other units they could/will float to: NA
• What type of EMR is used: Cerner with Careport (Allscripts)
• Required Skills/Experience: Licensed RN (multistate or TX RN), 2 years acute care UM experience (or equivalent). Proficiency with InterQual/MCG and CMS regulations.
• Preferred Skills/Experience (if any): Use of payor portals, familiarity with managed Medicare and Medicaid insurers, Google Workspace, remote work experience
• Other Proficient and adaptable with multiple technologies simultaneously.

ROLES AND RESPONSIBILTIES:

• Provides health care services regarding admissions, case management, discharge planning and utilization review.
• Reviews admissions and service requests within assigned unit for prospective, concurrent and retrospective medical necessity and/or compliance with reimbursement policy criteria. Provides case
• management and/or consultation for complex cases.
• Assists departmental staff with issues related to coding, medical records/documentation, precertification, reimbursement, and claim denials/appeals.
• Assesses and coordinates discharge planning needs with healthcare team members.
• May prepare statistical analysis and utilization review reports as necessary.
• Oversees and coordinates compliance with federally mandated and third party payer utilization management rules and regulations.

BENEFITS:

• Medical
• Dental
• Vision
• 401(K)

EEOC Compliance:

We are an equal opportunity employer, and all qualified applicants will receive consideration for employment.

DISCLAIMER:

AI Usage Policy: Pacer Group uses AI to assist in screening applications.

Final hiring decisions are made by human recruiters based on qualifications and experience.