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    Utilization Review RN - Dallas, United States - Texas Institute for Surgery

    Texas Institute for Surgery
    Texas Institute for Surgery Dallas, United States

    3 days ago

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    Description
    Job Details

    Job Location
    Texas Institute for Surgery LL SURG - Dallas, TX

    Salary Range
    $ $43.00 Hourly

    Job Category
    Health Care

    Description

    Job Summary:
    • The Utilization Management Nurse will provide precertification of inpatient hospitalizations and all outpatient procedures and services requiring authorizations. This role performs telephonic and/or concurrent review of inpatient hospitalizations and extended courses of outpatient. The nurse will use clinical judgement, utilization management, application of product benefits, understanding of regulatory requirements, and verification of medical necessity utilizing nationally recognized criteria. Acute Care Hospital Utilization Management Experience Required
    Job Duties
    • Facilitates progress through the continuum of care, from pre-admission through discharge
    • Provide consultation to medical, nursing staff, health information management, revenue cycle, and payers on potential issues with reimbursement of hospitalization.
    • Provides feedback to payers on patient's clinical status, and secures approvals for additional days of stay.
    • Assists and facilitate the physician peer-to-peer review process with insurance medical directors.
    • Prepares, drafts, and submit clinical on pre admission, denials, and additional days requests.
    • Leads UR Committee. Must work within scope of practice.
    • Assists Case Management with discharge planning and other tasks assigned.
    • Assists in aggregating data for quality trending
    • Adherence to Best Practices including CMS, Joint Commission and State laws governing medical necessity and adherence to the Case Management Standards
    • All other tasks assigned by leadership.
    Qualifications

    Experience and Education:
    • Acute Care Hospital Utilization Management Experience Required
    • Five years Inpatient clinical nursing experience in an acute care hospital setting required.
    • Minimum of two years Utilization Management acute care setting experience required.
    • Minimum of one year drafting and submitting reconsiderations and appeals to Medicare experience.
    • Preferably a minimum of two years of experience in an acute care setting.
    • BLS Certified
    • Licensed Vocational Nursing or Associate Degree in Nursing
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