- Applies demonstrated clinical competency and judgment in order to perform comprehensive assessments of clinical information and treatment plans and apply medical necessity criteria in order to determine appropriate level of care
- Resource/Utilization Management appropriateness: Assess assigned patient population for medical necessity, level of care and appropriateness of setting and services. Utilizes MCG/InterQual Care Guidelines and/or health system approved tools to track impact and variance
- Uses appropriate criteria sets for admission reviews, continued stay reviews, outlier reviews and clinical appropriateness recommendations
- Coordinate and facilitate correct identification of patient status.
- Analyze quality and comprehensiveness of documentation and collaborates with physician and treatment team to obtain documentation needed to support level of care
- Facilitates joint decision-making with the interdisciplinary team regarding any changes in the patient status and/or negative outcomes in patient responses
- Demonstrates, maintains, and applies current knowledge of regulatory requirements relative to work process in order to ensure compliance, i.e. IMM, Code 44
- Utilize independent scope of practice to identify, evaluate and provide utilization review services for patients and analyze information supplied by physicians (or other clinical staff) to make timely review determinations, based on appropriate criteria and standards
- Take appropriate follow-up action when established criteria for utilization of services are not met
- Proactively refer cases to the physician advisor for medical necessity reviews, peer-to-peer reviews, and denial avoidance
- Effectively collaborate with the Interdisciplinary team including the Physician Advisor for secondary reviews
- Proactively review patients at point of entry, prior to admission, to determine medical necessity of a requested hospitalization and the appropriate level of care or placement for the patient
- Review surgery schedule to ensure planned surgeries are ordered in the appropriate status and that necessary authorization has been obtained as required by the payor or regulatory guidance (ie., CMS Inpatient Only List, Payor Prior Authorization matrix, etc.)
- Regularly review patients who are in the hospital in Observation status to determine if the patient is appropriate for discharge or if conversion to inpatient status is appropriate
- Proactively identify and resolve issues regarding clinical appropriateness recommendations, coverage, and potential or actual payor denials.
- Maintain consistent communication and exchange of information with payors as per payor or regulatory requirements to coordinate certification of hospital services
- Coordinate and facilitate patient care progression throughout the continuum and communicate and document to support medical necessity at each level of care
- Evaluate care administered by the interdisciplinary health care team and advocate for standards of practice
- Analyze assessment data to identify potential problems and formulate goals/outcomes
- Follows the Corporate Guidelines related the Health Insurance Portability and Accountability ACT (HIPPA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
- Attend scheduled department staff meetings and/or interdepartmental meetings as appropriate
- Adjust to frequently changing workloads and frequent interruptions
- May be asked to work overtime or take call
- May be asked to travel to other facilities to assist as needed.
- Other duties as assigned.
- Possesses and demonstrate technology literacy and the ability to work in multiple technology systems
- Act as a catalyst for change in the organization; responds to change with flexibility and adaptability; demonstrates the ability to work together for change
- Translate strategies into action steps; monitors progress and achieves results.
- Demonstrate the confidence, drive and ability to face and overcome challenges and obstacles to achieve organizational goals
- Demonstrate competence to perform assigned responsibilities in a manner that meets the population-specific and developmental needs of patients served by the department
- Possess negotiating skills which support the ability to interact with physicians, nursing staff, administrative staff, discharge planners, and payers
- Excellent verbal and written communication skills, knowledge of clinical protocol, normative data and health benefit plans, particularly coverage and limitation clauses
- Associate of Nursing Degree required, BSN preferred
- RN License for state of employment required, compact accepted
- 2+ years of experience in Utilization Review
- Knowledge of criteria sets including InterQual and MCG
- Excellent written and verbal communication skills
- Critical and analytical thinking skills
- Certification in Case Management preferred
-
RN Utilization Review
2 weeks ago
Tekaccel Irving, United StatesSummary: · The RN Utilization Review II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. · This RN is responsible for performing a variety of pre-admission, concurrent, and re ...
-
RN Utilization Review II
3 weeks ago
Impresiv Health Irving, United StatesTitle: RN Utilization Review II · Description: The RN Utilization Review II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This RN is responsible for performing a variety of ...
-
Registered Nurse Utilization Review
2 weeks ago
CornerStone Irving, TX, United StatesCornerStone Medical is looking for a Registered Nurse Utilization Review for a state of the art hospital system in Irving, TX. This is an onsite role. Current RN Compact License required 8 am - 5 pm Monday - Friday $37/ Hr Summary: The RN Utilization Registered Nurse, Registered, ...
-
Registered Nurse Utilization Review \ 1366
2 weeks ago
TalentBurst, Inc. Irving, TX, United StatesJob Title: Registered Nurse Utilization Review · Location: Irving, TX, 75038 · Duration: 13 Weeks · Shift: Monday - Friday 8 am - 5 pm · Pay Rate: $30/hr. - $35/hr. · Notes: Temp to Perm - Local Candidates only. Current RN Compact license required · Summary:The RN Utilization Rev ...
-
Registered Nurse Utilization Review \ 1366
2 weeks ago
Softpath System LLC Irving, TX, United StatesArea: HPUtilization Mgmt 7065 / 1346 · Class: RN Utilization Review · Shift: 1 · Start: 08:00:00 · End: 17:00:00 ...
-
Utilization Review RN
2 weeks ago
Texas Institute for Surgery Dallas, United StatesJob 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 out ...
-
Utilization Review RN
3 weeks ago
HireOps Staffing LLC Dallas, United StatesThis position is fully remote, however, you must reside in the State of Texas · The position is a contract for about 6 months. · RN working in the insurance or managed care industry using medically accepted criteria to validate the medical necessity and appropriateness of the tre ...
-
Utilization Review Specialist
3 weeks ago
Carrollton Springs Carrollton, United StatesOverview: · Carrollton Springs is a 72-bed behavioral hospital located Carrollton, TX. The hospital offers inpatient and outpatient mental health and addiction treatment to adults, adolescents and their families. At Carrollton Springs we are dedicated to Changing Peoples Lives ...
-
Utilization Review Specialist
2 weeks ago
Mesa Springs Fort Worth, United StatesOverview: · Mesa Springs is a 72-bed behavioral hospital located in Fort Worth, TX. The hospital offers inpatient and outpatient mental health and addiction treatment to adults, adolescents and their families. At Mesa Springs we are dedicated to Changing Peoples Lives. · Mesa S ...
-
Utilization Review Specialist
2 weeks ago
Springstone Fort Worth, United StatesOverviewMesaSprings is a 72-bed behavioral hospital located in Fort Worth, TX.The hospital offers inpatient and outpatient mental health and addiction treatment to adults, adolescentsand their families. At MesaSprings we are dedicated to Changing Peoples Lives.Mesa Springs is loo ...
-
Utilization Review Specialist
4 weeks ago
Springstone Fort Worth, United StatesOverview · MesaSprings · is a 72-bed behavioral hospital located in Fort Worth, TX.The hospital offers inpatient and outpatient mental health and addiction treatment to adults, adolescentsand their families. At · MesaSprings · we are dedicated to Changing Peoples Lives. · Me ...
-
Director of Utilization Review
2 weeks ago
ADDICTION AND MENTAL HEALTH SERVICES, LLC Waxahachie, United StatesJob Description · Job DescriptionTwo years minimum experience in utilization review. Must possess good grammatical and communication skills. Must be skilled in Microsoft Office applications and have a working knowledge of office equipment. · 1. Must be able to see and read handwr ...
-
Utilization Review Specialist
1 week ago
Springstone, Inc Ft. Worth, United StatesMesa Springs is a 72-bed behavioral hospital located in Fort Worth, TX. The hospital offers inpatient and outpatient mental health and addiction treatment to adults, adolescents and their families. At Mesa Springs we are dedicated to Changing People's Lives. · Mesa Springs is lo ...
-
Utilization Review Coordinator
2 weeks ago
Carrus Hospital Mansfield, United StatesCarrus Care Mansfield mental health clinic serving the pediatric and adolescent population, is seeking a Utilization Review Coordinator (RN)ESSENTIAL FUNCTIONS:1. Responsible for coordinating andmonitoring day-to-day operations of the utilization management program for theoutpati ...
-
Utilization Review Coordinator
2 weeks ago
Carrus Hospital Frisco, United StatesCarrus Care Frisco mental health clinic serving the pediatric and adolescent population, is seeking a Utilization Review Coordinator (RN)ESSENTIAL FUNCTIONS:1. Responsible for coordinating andmonitoring day-to-day operations of the utilization management program for theoutpatient ...
-
Utilization Review Specialist
4 weeks ago
Mesa Springs Fort Worth, United StatesOverview: · Mesa Springs is a 72-bed behavioral hospital located in Fort Worth, TX. The hospital offers inpatient and outpatient mental health and addiction treatment to adults, adolescents and their families. At Mesa Springs we are dedicated to Changing Peoples Lives. · Mesa S ...
-
OCOK Utilization Review Specialist
3 weeks ago
Shelby American Inc Fort Worth, United StatesPosition Function : Responsible for ensuring that youth receive the most appropriate level of residential services for well-being and to achieve permanency. Responsible for ensuring that exceptional services and/or placement waivers are secured and reviewed, with all deadlines me ...
-
OCOK Utilization Review Specialist
2 weeks ago
ACH Child and Family Services Fort Worth, United StatesPosition Function : Responsible for ensuring that youth receive the most appropriate level of residential services for well-being and to achieve permanency. Responsible for ensuring that exceptional services and/or placement waivers are secured and reviewed, with all deadlines me ...
-
OCOK Utilization Review Specialist
3 weeks ago
Shelby American Inc Fort Worth, United StatesPosition Function · : · Responsible for ensuring that youth receive the most appropriate level of residential services for well-being and to achieve permanency. Responsible for ensuring that exceptional services and/or placement waivers are secured and reviewed, with all deadli ...
-
Utilization Review Case Manager
3 weeks ago
Dallas Behavioral Healthcare Hospital Desoto, United StatesThe Utilization Review Case Manager is responsible for working with insurance companies and managed care systems for the authorization, concurrent and retrospective review of inpatient admissions and services. This position will obtain authorization for each admitted patient. Rev ...
rn utilization review ii - Irving, TX , USA, United States - Impresiv Health
Description
Title: RN Utilization Review IIDescription: The RN Utilization Review II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This RN is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services CMS Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and Joint Commission regulations and guidelines related to UM. This RN effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The RN Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the organizations mission and values.
What You Will Do:
You Will Be Successful If:
What You Will Bring:
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv
