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At Houston Methodist, the Utilization Review Specialist Nurse (URSN) position is a licensed registered nurse (RN) who comprehensively conducts point of entry and concurrent medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, payer guidelines, CMS, and other state agencies. In addition to performing the duties of the URN, this position is able to cover a multitude of utilization review functions through point of entry, observation progression of care management, concurrent review and denials reviews. Additionally, the URSN will prospectively or concurrently determines the appropriateness of inpatient or observation services following review of relevant medical documentation, medical guidelines, and insurance benefits and communicates information to payers in accordance with contractual obligations. The URSN position serves as a resource to the physicians and provides education and information on resource utilization and national and local coverage determinations (LCDs & NCDs). This position collaborates with case management in the development and implementation of the plan of care and ensures prompt notification of any denials to the appropriate case manager, denials, and pre-bill team members, as well as management. The URSN position helps drive change by identifying areas where performance improvement is needed (e.g., day-to-day workflow, education, process improvements).
