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San Angelo

    Utilization Review Nurse - San Angelo, TX, United States - Shannon Health

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    Healthcare
    Description
    Job Summary


    The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination.

    This individual supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers.

    This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated, and reported.

    This individual identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis.

    He/she actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff. This individual maintains current and accurate knowledge regarding commercial and government payers and CIHQ regulations/guidelines/criteria related to UM. The UR Nurse effectively and efficiently manages a diverse workload in a dynamic regulatory environment. The UR Nurse is a member of, and provides support to, the hospital's UR Committee.

    He/she collaborates with multiple leaders at various levels throughout Shannon Health, for the purpose of supporting and improving the UM program.

    Education

    Education Type

    Program of Study

    Required/Preferred

    High School Diploma

    N/A

    Required

    Associate's degree

    Nursing

    Required

    Bachelor's degree

    Nursing

    Preferred

    Experience

    Number of Years

    Type of Experience

    Required/Preferred

    5 Years

    Clinical nursing

    Required

    1 Year

    Inpatient Utilization Review

    Preferred

    Certification & Licensures

    Certification/Licensure Type

    Required/Preferred

    Registered Nurse (RN),

    with Authorization to Practice in the State of Texas

    Required

    ACM (Accredited Case Manager) through ACMA

    Preferred

    CCM (Certified Case Manager) through CCMC

    Preferred

    *Must obtain within ninety (90) days of hire

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