Utilization Review Nurse PRN

The University of Texas Southwestern Medical Center; Dallas (TX); On-site; USD 85,000 - 115,000; Part time

Benefits offered by this job

PPO medical plan

Paid Time Off

Retirement programs (TRS)

Paid parental leave

Tuition reimbursement

Job summary

The University of Texas Southwestern Medical Center in Dallas is seeking a PRN Utilization Review Nurse to conduct medical necessity reviews for acute care. You will use evidence-based guidelines to recommend levels of care, serve as a resource to medical staff, and ensure documentation meets criteria for admission decisions.

Qualified candidates are graduates of accredited nursing programs with an active Texas RN license and at least 5 years of clinical experience including 2 years in

Qualifications

• RN license in Texas and nursing degree from an accredited program.
• Experience in clinical setting with utilization review and admission decisions.

Responsibilities

• Collaborate with Central Scheduling to obtain accurate clinical information for authorization.
• Conduct admission reviews for Medicare/Medicaid and private insurance.
• Review new admissions at entry with available clinical data.
• Communicate with admitting physicians when documentation does not support level of care.
• Apply hospital-approved tools to determine level of care for inpatient or observation services.
• Keep current on regulatory changes affecting delivery/reimbursement of acute care services.
• Collaborate with admitting physician to ensure timely level-of-care determinations.
• Escalate barriers to appropriate departments to improve patient flow.
• Participate in daily huddles and department meetings and education offerings.
• Educate care team on access to various levels of care and evidence-based protocols.

Skills

Utilization review

Clinical experience

Epic CCM

Communication

Education

RN license (Texas)

Tools

Epic CCM

Job description

PRN

Requires flexible, PRN availability Monday - Friday, 8am - 5pm

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 number 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

• 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. and
  Prior experience with Epic CCM.
  
• Licenses and Certifications
  (RN) REGISTERED NURSE Holds an active unrestricted license in the State of Texas. and
  

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.

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.