- Hybrid-remote. You will work mostly remote and are required to work onsite for quarterly meetings.
- 3, 12 hour shifts. Saturday, Sunday, Monday.
- Performs initial, concurrent, discharge and retrospective reviews.
- Uses evidence-based medical guidelines to resolve the medical appropriateness of inpatient and outpatient services; Assesses patient needs; Uses knowledge of the nursing process and pathophysiology to interpret the needs or requirements of patients; Identifies, escalates and resolves complex cases or issues as required.
- Reviews medical records to verify that the content helps an appropriate level of care (inpatient, observation, bedded outpatients) or type of service.
- Alerts and partners with appropriate Utilization Review, Physician leadership and/or Provider Team personnel concerning patients who do not meet medical appropriateness criteria.
- Coordinates with necessary parties when there are potential or actual denials.
- Facilitates appeals or the delivery of appeal instructions when denials occur.
- Facilitates authorization process for admissions and continued stays.
- Uses knowledge of nursing process and pathophysiology to anticipate discharge needs.
- May participate in discharge planning through discussions with the care team as needed.
- Communicates issues or trends with specific entities, providers or payors to the appropriate leadership.
- Provides help to complex cases or escalations within scope of licensure or refers them to appropriate leadership.
- Identifies, documents and communicates potential quality assurance or risk management issues as appropriate.
- Participates in process improvement projects, including the evaluation, development and implementation of protocols, policies, and procedures to continuously enrich care coordination efforts and ensure evidence-based processes are utilized.
- Performs service recovery efforts to help provider and member satisfaction.
- Advanced knowledge of health care modalities, pathophysiology, therapies, terminology and equipment.
- Advanced knowledge of health care modalities, pathophysiology, therapies, terminology and equipment.
- Ability to know the customer's point of view and take ownership of creating a solution to their issues.
- Knowledge and use of discharge planning, case management referral criteria, utilization review and levels of care.
- Knowledge of applicable federal and state regulatory requirements, including TDI, CMS, DOL, HHSC and NCQA standards and requirements.
- Must be able to communicate thoughts clearly; both verbally and in writing.
- Relational skills to interact with a wide-range of constituencies.
- Must have critical thinking and problem-solving skills.
- Ability to stabilize multiple demands and respond to time constraints.
- Ability to examine, know and act on detailed clinical care documentation.
- General computer skills, including but not limited to Microsoft Office, information security, scheduling and payroll systems, electronic medical documentation, and email.
- Certified Case Manager (CCM), Accredited Case Manager (ACM), or Certified Managed Care Nurse (CMCN) preferred.
- Eligibility on day 1 for all benefits
- Dollar-for-dollar 401(k) match, up to 5%
- Debt-free tuition assistance, offering access
- Immediate access to time off benefits
- EDUCATION - Associates Degree
- MAJOR - Nursing
- EXPERIENCE - 3 years of experience
- CERTIFICATION/LICENSE/REGISTRATION - Registered Nurse (RN)
-
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
6 days 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 ...
-
Senior Director, Utilization Review
1 week ago
Other Executive Dallas, TX, United States· JOB DESCRIPTION: · Under the direction of the VP of Case Management & Continuing Care, the Sr. Director of Utilization Review (UR) is responsible for overseeing the development, implementation, and performance management of Utilization Review services performed across the Tene ...
-
Senior Director, Utilization Review
1 week ago
Other Executive Dallas, TX, United StatesUnder the direction of the VP of Case Management & Continuing Care, the Sr. Director of Utilization Review (UR) is responsible for overseeing the development, implementation, and performance management of Utilization Review services performed across the Tenet enterprise. Leads Te ...
-
Registered Nurse Utilization Review
2 days ago
University of Texas Southwestern Medical Center Dallas, TX, United StatesRegistered Nurse Utilization Review · Registered Nurse Utilization Review Full Time Days Friday to Tuesday 8:00 AM - 4:30 PM · Why UT Southwestern? With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and ...
-
Senior Director, Utilization Review
1 week ago
Other Executive San Francisco, United States PermanentJOB DESCRIPTION: · Under the direction of the VP of Case Management & Continuing Care, the Sr. Director of Utilization Review (UR) is responsible for overseeing the development, implementation, and performance management of Utilization Review services performed across the Tenet ...
-
Case Management Utilization Review RN
1 week ago
Steward Health Care Dallas, United States Full timeThe Care Manager assumes primary responsibility for documentation of appropriate medical necessity for the inpatient status or placement in observation. Communicates with the physicians and clinicians. Assures clinical information is sent to the payor timely to complete the autho ...
-
Director of Utilization Review
1 day ago
ADDICTION AND MENTAL HEALTH SERVICES, LLC Duncanville, United StatesJob Description · Two years experience in utilization review required. Good communication and grammatical skills are a must. Proficiency in Microsoft Office applications and familiarity with office equipment necessary. · Ability to read handwritten or printed notes and follow ins ...
-
Parkland Health and Hospital System Dallas, United StatesInterested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and ...
-
Nurse (Utilization Review Nurse)
2 weeks ago
Justice, Bureau Of Prisons/Federal Prison System Fort Worth, United States Full timeThis position is located in the Health Services Department of a Bureau of Prisons (BOP), Medical Referral Center (MRC), Medical Care Level 3 facility, or Federal Correctional Complex (FCC). Serves as the Utilization Review Nurse and assists in quality improvement activities throu ...
-
Team Lead UR RN Case Manager
5 days ago
Steward Health Care Dallas, United States Full timePOSITION SUMMARY: · The Utilization Review Case Manager Lead will work with the Utilization Review Case Manages and other facility staff to coordinate the appropriate information and actions necessary to ensure proper authorizations are obtained for care of patients through nursi ...
-
Clinical Coverage Review Medical Director
1 week ago
UnitedHealth Group Dallas, United States Full timeOptum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel ...
-
Service Waterproofing Estimator
5 days ago
KPost Company Dallas, United StatesKPost is searching for a Waterproofing Estimator to join the Service Department. This role will be responsible for collecting pertinent job information from on-site visits including but not limited to building measurements, building information and overall building conditions, ma ...
-
Property Accountant
3 weeks ago
Financial Additions Dallas, United StatesFinancial Additions has partnered with an excellent real estate client in search of a Senior Property Accountant. Please take a moment to review the job description below and apply. Someone from our team will get back to you in 24-48 hours. · Description · Manage full-cycle acco ...
-
Authorization Specialist II
5 days ago
TEKsystems Dallas, United StatesPosition Purpose: · Acts as a resource and supports the prior authorization request process to ensure that all authorization requests are addressed properly in the contractual timeline. Supports utilization management team to document authorization requests and obtain accurate an ...
-
Associate Electrical Engineer
2 weeks ago
Bureau Veritas Group Dallas, United States PermanentAssociate Electrical Engineer - (Junior Level EE) · Summary · The Associate Electrical Engineer will be part of Bureau Veritas (BV) Owner's Engineering and Technical Advisory group, a multi-discipline team focusing on servicing clients in the renewable power and utilities indus ...
-
Civil Design Engineer
1 day ago
The Bexar Company Dallas, United StatesOur client is in search of a self-driven civil designer or civil engineer to join their firm. You will be responsible for creating and implementing innovative designs for various civil projects. Your expertise in using programs such as Civil 3D will allow you to create accurate a ...
-
Senior Mechanical Engineer
2 weeks ago
Premier Group Recruitment Dallas, United StatesRole: Senior Mechanical Engineer · Location: Dallas, Texas · VISA: Not offering sponsorship. · Relocation: Offered · Type: Fully On-Site · I am seeking a seasoned Mechanical Engineer to join my client's team in Dallas, TX. · You will design mechanical HVAC systems for various pr ...
-
Corporate Tax Senior Associate
1 week ago
Grant Thornton Dallas, United States Full timeAs the Corporate Tax Senior Associate, you'll be a member of our corporate tax practice and work on business income tax planning, corporate compliance, and ASC 740 income tax accounting (either tax provision preparation or audit support) projects. The Corporate Tax Solutions Fami ...
-
sbe compliance officer.0004500
1 week ago
Dallas County Dallas, United StatesBrief Description · Responsible for the development, oversight and maintenance of Dallas County's Small Business Enterprise (SBE) contract data collection system, reporting system(s), and records, including SBE/HUB/DBE utilization; Ensures prime contractor adherence to the SBE p ...
Utilization Review RN - Dallas, TX, United States - Baylor Scott & White Health
![baylor scott & white health background](https://contents.bebee.com/companies/us/baylor-scott-white-health/background-8yTp4.png)
Description
SCHEDULE:
JOB SUMMARY
The Utilization Review Registered Nurse (RN) provides a clinical review of cases using medical necessity criteria to resolve the medical appropriateness of inpatient and outpatient services.
Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care.
Provides ongoing communication with the health plan, provider utilization and/or care coordination departments regarding medical necessity for prospective, concurrent, and retrospective reviews.
Partners as a team to ensure that medical records help the level of services being delivered.ESSENTIAL FUNCTIONS OF THE ROLE
KEY SUCCESS FACTORS
Note:
Benefits may vary based on position type and/or level
QUALIFICATIONS