Utilization Review Nurse, FT Days (58024)

El Paso Childrens Hospital Corporation; El Paso (TX); In loco; USD 70.000 - 95.000; Tempo pieno

Descrizione del lavoro

Paycom - ATS is seeking an Experienced Utilization Management Nurse in El Paso, TX to monitor hospital utilization and ensure appropriate admissions and stays. You will integrate clinical and billing knowledge while coordinating peer reviews with physician advisers to support policy and process improvements.

The role requires an RN with UM experience, familiarity with ICD-10/DRGs, and strong communication skills in a fast-paced hospital environment.

Competenze

• Two years experience with Utilization Management.
• Experience with InterQual and/or Milliman Care Guidelines.
• Strong organizational and time management skills.
• Current RN License to practice in the State of Texas.
• Associate’s Degree in Nursing; BSN preferred.

Mansioni

• Monitor adherence to the hospital’s utilization review plan for efficient use of services.
• Ensure appropriateness of hospital admissions and extended stays.
• Collaborate with physician advisers to support policy development and process improvement.

Conoscenze

Communication skills

Analytical problem solving

HIPAA knowledge

ICD-10/DRGs

Medical necessity

Utilization management

Negotiation

Time management

Billing integration

Formazione

Associate’s Degree in Nursing

BSN preferred

Descrizione del lavoro

Job Details: Level: Experienced, Job Location: San Jacinto Plaza - Sunflower Building - El Paso, TX 79901, Position Type: Full Time, Education Level: 4 Year Degree, Travel Percentage: None, Job Shift: Rotating, Job Category: Health Care, To monitor adherence to the hospital’s utilization review plan to ensure the effective and efficient use of hospital services. Responsible for ensuring the appropriateness of hospital admissions and extended hospital stays. An understanding of the severity of an array of illnesses, intensity of service, and care coordination needs are the key, as the nurse must integrate clinical knowledge with billing knowledge to review, evaluate and arrange peer to peers when clinical denials related to medical necessity of the patient while hospitalized. UM nurse will work closely in collaboration with physician advisers to support policy development, and process improvement.

Qualifications:

• Two (2) years prior experience with Utilization Management.
• Previous training and demonstrated competence in negotiations, quality assurance, case management outcomes, and keyboarding/computer use.
• Experience with InterQual and/or Milliman Care Guidelines. Strong organizational and time management skills.
• Ability to work on extremely complex problems where analysis of situation or data requires an evaluation of intangible variance factors.

License/Registration/Certification:

• Current RN License to practice in the State of Texas.

Education and Training:

• Associate’s Degree in Nursing, BSN preferred.

Skills:

• Ability to utilize proficient verbal, written and interpersonal communication skills.
• Ability to work on extremely complete problems where analysis of situations or data requires an evaluation of intangible variance factors.
• Knowledge of managed care, reimbursement and utilization management.
• Knowledge of current International Classification of Disease (ICD-10), Diagnostic Related Groups (DRGs), and medical necessity criteria.
• Knowledge of claims denials and appeals processing
• Ability to coordinate and manage multiple priorities, projects simultaneously, reprioritizing as necessary
• Ability to self-motivate, multi-task and prioritize in a fast paced environment.
• Ability to use analytical and problem solving skills.
• Knowledge of HIPAA standards.
• Knowledge of various insurance plan coverages for Home Health, DME, SNF, LTAC agencies.
• Works well with people of all social, economic, and cultural backgrounds.
• Strong customer service orientation.
• Knowledgeable regarding community resources.
• Knowledge of basic computer, word-processing, and spreadsheet skills, Microsoft.
• Ability to operate standard office equipment.
• Knowledge of English grammar, punctuation and spelling.