Utilization Review Nurse

UT Southwestern Medical Center; Dallas (TX); On-site; USD 85,000 - 115,000; Full time

Job summary

UT Southwestern Medical Center in Dallas is seeking an experienced Utilization Review RN to conduct medical certification reviews for acute care services. You will apply nationally recognized guidelines to determine level of care and support physicians with admission decisions.

You will collaborate with the Central Scheduling Department, coordinate with care teams, stay current on regulatory changes, and help ensure high-quality, cost-effective care.

Qualifications

• RN license in Texas with nursing degree.
• 5 years total experience including 2 years clinical and 3 years utilization review.
• Epic CCM experience preferred.

Responsibilities

• Collaborates with Central Scheduling to obtain authorization.
• Conducts admission reviews for Medicare/Medicaid and private insurance.
• New admission reviews are done concurrently at entry when order placed.
• Communicates with admitting physicians when documentation does not support hospital level of care.
• Uses hospital-approved medical necessity tool to determine level of care for inpatient or observation/outpatient services.
• Keeps current on Federal, State and local regulatory changes affecting utilization management.
• Collaborates with admitting physician to provide accurate level of care at review.
• Escalates progression-of-care barriers to appropriate departments.
• Participates in daily huddles and departmental meetings.
• Educates care team on access to and use of levels of care.
• Promotes evidence-based protocols and/or order sets to influence high-quality, cost-effective care.
• Serves as a resource to physicians and billing for coverage and compliance issues.
• Completes reviews within department policies and quality standards.

Skills

Performance improvement

Basic computer skills

Medical necessity tool

Education

Nursing degree (RN)

Tools

Epic CCM

Job description

Utilization Review RN

Work Schedule : Thursday - Sunday; (4) 10-Hour Day Shifts

WHY UT SOUTHWESTERN?

With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the No. 1 hospital in Dallas-Fort Worth according to U.S. News & World Report , we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you'll discover a culture of teamwork, professionalism, and a rewarding career!

JOB SUMMARY

Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations and documentation requirements.

BENEFITS

UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include:

• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100% coverage for preventive healthcare-no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer

Learn more about these and other UTSW employee benefits!

EXPERIENCE AND EDUCATION

Required

Education

Graduate of accredited nursing program and holds an active unrestricted RN license in the State of Texas.

Experience

5 years experience to include 2 years of clinical experience and minimum of 3 years of recent utilization review experience.

Prior experience with Epic CCM.

Licenses and Certifications

(RN) REGISTERED NURSE holds an active unrestricted RN license in the State of Texas.

Preferred

Experience

Acute care experience preferred.

JOB DUTIES

Collaborates with the Central Scheduling Department (CSD) team to provide accurate and complete clinical information in order to obtain authorization.

Conducts admission reviews for Medicare and Medicaid beneficiaries as well as private insurance members and self-pay patients utilizing evidence-based guidelines.

New admission reviews are done concurrently at the point of entry when the admission order is placed and necessary clinical information is available in the medical record.

Communicate with admitting physicians and physician advisors when documentation does not appear to support hospital level of care.

Use hospital approved medical necessity tool to determine level of care for inpatient or observation/outpatient services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two-midnight stay.

Keeps current on all Federal, State and local regulatory changes that affect delivery or reimbursement of acute care services within the scope of Utilization Management. Uses knowledge of national and local coverage determinations to appropriately advise physicians.

Proactively collaborates with admitting physician to provide accurate level of care determination at the time of review.

Escalates identified progression-of-care/patient flow barriers to appropriate departments.

Actively participates in daily huddles, departmental meetingsand education offerings.

Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes.

Educates members of the patient's care team on the appropriate access to and use of various levels of care.

Promotes use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care.

Serves as a resource person to physicians, care coordinators, physician offices and billing office for coverage and compliance issues.

Completes all reviews within department established policies and best practice standards. Meets department quality standards as established for the department, ie: Inter-rater Reliability audits, completing all initial reviews within established time frames, completes concurrent and discharge reviews to meet department and industry standards.

Performs other duties as assigned.

Knowledge, Skills and Abilities

Actively participates in the department's performance improvement initiatives.

Basic computer skills and knowledge.

Expert knowledge of hospital approved, evidence based medical necessity tool and knowledge of local and national coverage determinations.

Identifies avoidable days (quality