Utilization Review Nurse PRN

UT Southwestern Medical Center • Dallas, TX

9d

About The Position

This PRN position requires flexible availability Monday - Friday, 8am - 5pm. The Utilization Review Nurse will conduct medical certification reviews for medical necessity for acute care facilities and services. They will use nationally recognized, evidence-based guidelines approved by medical staff to recommend the 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.

Requirements

• Graduate of accredited nursing program and holds an active unrestricted RN license in the State of Texas
• 5 years experience to include 2 years of clinical experience and minimum of 3 years of recent utilization review experience.
• Prior experience with Epic CCM.
• Holds an active unrestricted license in the State of Texas.

Nice To Haves

• Acute care experience preferred

Responsibilities

• 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 meetings and 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.

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

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Education Level: No Education Listed