Utilization Review Nurse PRN

UT Southwestern Medical Center; Dallas (TX); On-site; USD 80,000 - 110,000; Part time

Benefits offered by this job

PPO medical plan

Preventive care coverage

Paid Time Off

Retirement (TRS)

Parental Leave

Wellness programs

Tuition Reimbursement

Job summary

UT Southwestern Medical Center in Dallas is seeking a Utilization Review Nurse - RN (PRN). The role requires flexible availability Monday through Friday, 8am–5pm, to conduct utilization reviews for acute care services and ensure medical necessity per guidelines.

The ideal candidate holds an accredited nursing degree and active Texas RN license, with 5 years of nursing experience including 2 years in clinical settings and 3 years in utilization review.

Qualifications

• RN license in Texas and graduation from an accredited nursing program.
• At least 5 years in nursing with 2 years in clinical settings and 3+ years in utilization review.
• Experience with Epic CCM is preferred.

Responsibilities

• Conduct medical certification reviews for medical necessity for acute care.
• Review admissions for Medicare/Medicaid and private insurance using evidence-based guidelines.
• Communicate with admitting physicians when documentation does not support level of care.
• Escalate progression-of-care barriers to appropriate departments.
• Participate in daily huddles and department meetings.

Skills

Utilization review

Clinical experience

Education

RN license (Texas)

Tools

Epic CCM

Job description

Utilization Review Nurse - RN

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

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.

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 provi