Utilization Review Nurse

UT Southwestern Medical Center•Dallas, TX

2d•Onsite

About The Position

Conduct medical certification reviews for medical necessity for acute care facilities and services. Use nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to physicians, and serve as a resource to medical staff on admission qualifications, resource utilization, national and local coverage determinations, and documentation requirements. The schedule is Thursday through Sunday, with four 10-hour day shifts. The position is based in an office setting.

Requirements

Graduate of an accredited nursing program.
Active, unrestricted Registered Nurse license in the State of Texas.
Five years of experience, including two years of clinical experience and a minimum of three years of recent utilization review experience.
Prior experience with Epic CCM.
Basic computer skills and knowledge.
Expert knowledge of the hospital-approved, evidence-based medical necessity tool and knowledge of local and national coverage determinations.
Ability to identify avoidable days and quality or risk issues and make appropriate referrals.
General good health and stress-coping ability.
Ability to speak and hear to support discussions with physicians, patients, and other healthcare team members.
Near vision acuity for accurately reading computer screens and recording information on patient charts.

Nice To Haves

Acute care experience preferred.

Responsibilities

Collaborate with the Central Scheduling Department team to provide accurate and complete clinical information to obtain authorization.
Conduct admission reviews for Medicare and Medicaid beneficiaries, private insurance members, and self-pay patients using evidence-based guidelines.
Perform new admission reviews 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 care.
Use the hospital-approved medical necessity tool to determine inpatient or observation/outpatient level of care based on physician documentation, history and physical, treatment plan, potential risks, and the basis for expecting a two-midnight stay.
Stay current on Federal, State, and local regulatory changes affecting delivery or reimbursement of acute care services within Utilization Management.
Use knowledge of national and local coverage determinations to advise physicians.
Collaborate proactively with admitting physicians to provide an accurate level-of-care determination at the time of review.
Escalate identified progression-of-care and patient-flow barriers to appropriate departments.
Participate in daily huddles, departmental meetings, and educational offerings.
Identify and record preventable delays or avoidable days due to failures in progression-of-care processes.
Educate members of the patient's care team on appropriate access to and use of various levels of care.
Promote evidence-based protocols and order sets to influence high-quality, cost-effective care.
Serve as a resource to physicians, care coordinators, physician offices, and the billing office on coverage and compliance issues.
Complete reviews according to department policies and best-practice standards, meeting quality standards including inter-rater reliability audits and time frames for initial, concurrent, and discharge reviews.
Participate in departmental performance improvement initiatives.
Identify avoidable days and quality or risk issues and make appropriate referrals.
Confer with the Manager and/or Medical Director as appropriate.
Identify professional growth needs and pursue appropriate development opportunities.
Evaluate outcomes data to identify trends and improvement areas, including avoidable days and denial information.
Perform other duties as assigned.

Benefits

PPO medical plan, available day one at no cost for full-time employee-only coverage.
100% coverage for preventive healthcare with 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.
On-site childcare.
Paid holidays.
Wage and merit increases.