Utilization Review Nurse

UT Southwestern Medical Center•Dallas, TX

3d•Onsite

About The Position

Conducts medical certification reviews for medical necessity for acute care facilities and services. Uses nationally recognized, evidence-based guidelines approved by medical staff to recommend an appropriate level of care to physicians. Serves as a resource to medical staff on admission qualifications, resource utilization, national and local coverage determinations, and documentation requirements. The position collaborates with scheduling, physicians, physician advisors, care coordinators, and other departments to support accurate authorization, level-of-care decisions, patient flow, coverage compliance, and high-quality, cost-effective care. The schedule is Thursday through Sunday, consisting of four 10-hour day shifts. The role 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 at least 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 speak and hear to communicate with physicians, patients, and other healthcare team members.
Near-vision acuity sufficient to read computer screens and record information on patient charts.
General good health and ability to cope with stress.

Nice To Haves

Acute-care experience preferred.

Responsibilities

Collaborate with the Central Scheduling Department team to provide accurate and complete clinical information for 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 relevant 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.
Keep current on federal, state, and local regulatory changes affecting acute-care service delivery or reimbursement within Utilization Management, and use coverage-determination knowledge to advise physicians.
Collaborate proactively with admitting physicians to provide accurate level-of-care determinations at the time of review.
Escalate identified progression-of-care and patient-flow barriers to appropriate departments.
Participate in daily huddles, departmental meetings, and education offerings.
Identify and record preventable delays or avoidable days caused by failures in progression-of-care processes.
Educate patient-care team members on appropriate access to and use of different levels of care.
Promote evidence-based protocols and order sets to support 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 departmental policies and best-practice standards, meeting quality measures such as inter-rater reliability audits and initial, concurrent, and discharge review timelines.
Participate in departmental performance-improvement initiatives.
Identify avoidable days and quality or risk issues, make appropriate referrals, and 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 opportunities, 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.
Preventive healthcare coverage at 100% with no copay.
Paid Time Off available day one.
Retirement programs through the Teacher Retirement System of Texas (TRS).
Paid parental leave.
Wellness programs.
Tuition reimbursement.
Public Service Loan Forgiveness (PSLF) qualified employer.
Competitive benefits package including healthcare and paid holidays.
On-site childcare.