Utilization Review Nurse

The University of Texas Southwestern Medical Center; Dallas (TX); On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

PPO medical plan

Paid Time Off

TRS retirement

Parental Leave

Tuition Reimbursement

PSLF eligible

Job summary

UT Southwestern Medical Center seeks an experienced RN Utilization Review Specialist. You will conduct medical necessity reviews for acute care, determine level of care using evidence-based guidelines, and serve as a resource on admission qualifications, coverage determinations, and documentation requirements.

The role requires 5 years of experience with 2 years clinical and 3 years utilization review, plus an active RN license in Texas.

Qualifications

• Graduate of accredited nursing program
• Active unrestricted RN license in Texas
• 5 years experience including 2 years clinical and 3 years utilization review

Responsibilities

• Collaborates with Central Scheduling to provide accurate clinical information for authorization
• Conducts admission reviews for Medicare/Medicaid and private insurance using evidence-based guidelines
• Coordinates with admitting physicians to verify documentation supports level of care
• Uses hospital-approved medical necessity tools to determine inpatient vs observation level of care
• Escalates progression-of-care barriers to appropriate departments

Skills

RN license

Clinical experience

Utilization review

Education

RN program graduate

Tools

Epic CCM

Job description

Job Description

Description

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
• 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
• 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.

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 and risk issues), makes appropriate referrals. Confers with Manager and/or Medical Director as appropriate.
• Identifies the need for professional growth and seeks out appropriate development opportunities.
• Evaluates outcomes data to identify trends and areas for improvement (i.e. avoidable days, denial information).
• General good health and stress coping ability.
• Ability to speak and hear, to allow discussions with physicians, patients, and other members of the healthcare team.
• Possess near vision acuity for accurate reading of computer screens and recording on patient charts.

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

Physical Requirements

• Talking

Working Conditions

• Office Setting

Salary Information

Salary is commensurate with education, skills, and relevant experience.

SECURITY AND EEO STATEMENT

Security

This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information.

EEO

UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.

UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. In accordance with federal and state law, the University prohibits unlawful discrimination, including harassment, on the basis of: race; color; religion; national origin; gender, including sexual harassment; age; disability; citizenship; and veteran status. In addition, it is UT Southwestern policy to prohibit discrimination on the basis of sexual orientation, gender identity, or gender expression.

Copyright

Copyright 2017. The University of Texas Southwestern Medical Center 5323 Harry Hines Blvd., Dallas, Texas 75390 Phone [phone]