Utilization Review Nurse Jobs

About The Position

Requirements

• Two (2) years prior experience with Utilization Management.
• Current RN License to practice in the State of Texas.
• Associate’s Degree in Nursing.
• Previous training and demonstrated competence in negotiations, quality assurance, and case management outcomes.
• Experience with InterQual and/or Milliman Care Guidelines.
• Strong organizational and time management skills.
• Ability to work on extremely complex problems where analysis of situation or data requires an evaluation of intangible variance factors.
• Proficient verbal, written and interpersonal communication skills.
• Knowledge of managed care, reimbursement and utilization management.
• Knowledge of current International Classification of Disease (ICD-10), Diagnostic Related Groups (DRGs), and medical necessity criteria.
• Knowledge of claims denials and appeals processing.
• Ability to coordinate and manage multiple priorities and projects simultaneously, reprioritizing as necessary.
• Ability to self-motivate, multi-task and prioritize in a fast paced environment.
• Analytical and problem solving skills.
• Knowledge of HIPAA standards.
• Knowledge of various insurance plan coverages for Home Health, DME, SNF, LTAC agencies.
• Ability to work well with people of all social, economic, and cultural backgrounds.
• Strong customer service orientation.
• Knowledgeable regarding community resources.
• Basic computer, word-processing, and spreadsheet skills (Microsoft).
• Ability to operate standard office equipment.
• Knowledge of English grammar, punctuation and spelling.

Nice To Haves

• BSN preferred

Responsibilities

• Monitor adherence to the hospital’s utilization review plan.
• Ensure the effective and efficient use of hospital services.
• Ensure the appropriateness of hospital admissions and extended hospital stays.
• Integrate clinical knowledge with billing knowledge to review, evaluate and arrange peer to peers when clinical denials related to medical necessity of the patient while hospitalized.
• Work closely in collaboration with physician advisers to support policy development, and process improvement.