RN - Utilization Management - Full Time

Titus Regional Medical Center•Mount Pleasant, TX

17d

About The Position

The Utilization Management RN is responsible for evaluating medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities within the acute hospital setting. This role supports timely and effective patient care while ensuring compliance with payer requirements, Medicare/Medicaid guidelines, and hospital policies. The UM RN works closely with providers, nursing staff, case managers, and insurance representatives to promote appropriate resource utilization and high-quality care.

Requirements

Knowledge of InterQual, MCG, or similar utilization review criteria.
Understanding of Medicare/Medicaid, managed care, and commercial payer requirements.
Strong critical thinking, clinical judgment, and communication skills.
Proficient with EHR systems and UM software.
Ability to work independently in a resource-limited environment
Two years of clinical or case management experience preferred.
Registered Nurse currently licensed to practice in the State of Texas required.
BLS (Basic Life Support) within 30 days of hire date required.

Nice To Haves

CCM (Certified Case Manager) or ACM (Accredited Case Manager) preferred or willing to obtain it within 1 year.

Responsibilities

Knows and conforms to the Texas Nursing Practice Act, the Boards’ rules and regulations as well as Federal, State, or local laws, rules, or regulations affecting the RN's current area of nursing practice.
Conducts Clinical Reviews: Perform initial, concurrent, and retrospective reviews to determine medical necessity using evidence-based criteria (e.g., InterQual, MCG).
Reviews inpatient admissions, observation status, extended stays, and transfers.
Payer Communication: Submits clinical reviews to third-party payers.
Responds to insurance queries and participates in denial management and appeals.
Collaborates with Clinical Teams: Partner with physicians, nursing, case management, and social services to optimize patient care and length of stay.
Escalates cases to the physician advisor or medical director as needed.
Documentation & Reporting: Accurately documents UM activities and maintains records per hospital, CMS, and accrediting body standards.
Compliance & Education: Stays current with regulatory changes affecting UM practices.
Keeps director abreast of actions with patients, physicians/administrators, etc.
Able to work within EPIC and Indicia with adeptness and ease.
Participates in the daily huddle and coordinates care of the patient with the whole team.
Demonstrates an understanding of the operation of a health care computer system.
Performs general clerical duties as needed.
Demonstrates knowledge of utilization and financial issues of an acute health care facility.
Demonstrates effective oral and written communication skills.
Demonstrates supervision and leadership skills.
Adheres to and follows all patient experience initiatives.
Reports to and departs from work on time and as scheduled.
Performs other duties as assigned.
Must be able to deal with stress while maintaining composure.
Follows and adheres to TRMC vaccine policy(s) mandated by the Centers for Medicare & Medicaid Services (CMS).