- Coordinates the utilization review process for each treatment request.
- Provides clinical oversight and serves as a resource for non-clinical staff.
- Conducts initial clinical review for medical necessity against approved evidence-based guidelines.
- Evaluates need for continued or alternative treatment with provider.
- Discusses treatment options with requesting provider.
- Documents utilization review components within the Ethos Utilization Management System per State, Federal and URAC requirements, including data collection for analysis and trending.
- Refers, coordinates and interacts with peer clinical reviewers.
- Facilitates peer discussion during peer clinical review process.
- Partners with medical providers to promote best patient outcomes.
- Adheres to Ethos Policies and Procedures and URAC standards as appropriate to job functions.
- Assists in promoting and furthering the objectives of the Quality Management Program.
- Maintains confidentiality and security in all aspects of performance.
- Performs other related duties incidental to the work described herein.
- Completion of formal training in a health care field; and
- Active, unrestricted professional license or certification to practice as a health professional in a state or territory of the United States:
- An associate degree or higher in a health care field (RN); OR
- State license or state certificate in a health care field (LVN/LPN).
- Certified Case Manager (CCM), Health Care Quality & Management (HCQM) or equivalent certification preferred.
- 2 years of clinical nursing experience (direct patient care, administrative or combination post licensure).
- 1-year experience with workers' compensation/utilization management preferred.
- Knowledge of workers' compensation laws and regulations (preferred).
- Discretion and confidentiality.
- Good customer service skills.
- Strong oral and written communication skills.
- Computer knowledge required, including Microsoft Office products.
- Able to perform as part of a team.
- Analytical and interpretive skills.
- Strong organizational skills.
- Excellent interpersonal skills.
- Good negotiation skills.
- Ability to multi-task.
-
Electrophysiology Nurse Manager
19 hours ago
Heart Hospital of Austin Austin, United States**Introduction**: · Want to join a team of daring managers who care without reservations or limits? Our Heart Hospital of Austin team is looking for a(an) Electrophysiology Nurse Manager. HCA Healthcare is an advanced healthcare network that has committed up to $300 million to ou ...
-
Throughput Nursing Manager
1 week ago
St. David's North Austin Medical Center Austin, United States**Introduction**: · Are you ready to manage in a new era as a Throughput Nursing Manager where building a healthier tomorrow is more than a job? Our St. David's North Austin Medical Center team is committed to partnership, innovation, legacy and improving more lives in more ways. ...
-
Registered Nurse Case Manager
5 days ago
St. David's North Austin Medical Center Austin, United States**Introduction**: · Do you have the career opportunities as a Registered Nurse Case Manager you want with your current employer? We have an exciting opportunity for you to join St. David's North Austin Medical Center which is part of the nation's leading provider of healthcare se ...
-
Registered Nurse Case Manager
1 week ago
St. David's Medical Center Austin, United States**Introduction**: · Do you have the career opportunities as a(an) Case Manager you want with your current employer? We have an exciting opportunity for you to join St. David's Medical Center which is part of the nation's leading provider of healthcare services, HCA Healthcare. · ...
-
Registered Nurse Case Manager
3 days ago
St. David's South Austin Medical Center Austin, United States**Introduction**: · Are you passionate about the patient experience? At HCA Healthcare, we are committed to caring for patients with purpose and integrity. We care like family Jump-start your career as a Registered Nurse Case Manager today with St. David's South Austin Medical Ce ...
-
Hospice Nurse Case Manager
1 week ago
Aspen Hospice and Palliative Care North Austin, United StatesResponsibilities: · - Provide compassionate and comprehensive care to patients in hospice settings · - Conduct patient assessments and develop individualized care plans · - Collaborate with interdisciplinary team members to coordinate and implement patient care · - Educate patien ...
-
Registered Nurse Case Manager Prn
1 week ago
St. David's Medical Center Austin, United States**Introduction**: · Do you have the PRN career opportunities as a(an) Case Manager PRN you want with your current employer? We have an exciting opportunity for you to join St. David's Medical Center which is part of the nation's leading provider of healthcare services, HCA Health ...
-
Hospice Registered Nurse Case Manager
1 week ago
SUMMIT HOME HEALTH & HOSPICE Austin, United StatesSummit Home Health and Hospice is looking for a self-disciplined and team-oriented Full Time RN for the Austin areas with exceptional customer service skills. · **Summit Offers**: · - Competitive pay · - Work-life balance · - Supportive and collaborative environment · - Regularly ...
-
SUMMIT HOME HEALTH & HOSPICE Austin, United StatesSummit Home Health and Hospice is looking for a self-disciplined and team-oriented Home Health RN Case Manager with exceptional customer service skills. · **We Offer**: · - Competitive pay · - Exceptional benefits · - Fleet vehicle program and mileage reimbursement. · - Work-life ...
-
Nurse Manager
2 weeks ago
Urrly Austin, United StatesSeeking a RN/NP Supervisor · Your New Mission: Lead and inspire a dedicated nursing team in our Austin, TX facility. · Ensure exceptional health services and professional nursing care for all clients. · Master the art of nursing supervision, enhancing team performance and clie ...
-
Nurse Manager
4 hours ago
Central Health Austin, United StatesOverview · The Nurse Manager is responsible for the development, performance, and management of clinical patient care for nursing, medical assistants and other team members in clinical support roles. · Responsibilities · Essential Duties: · • Manages the clinical support team. ...
-
Nurse Manager
18 hours ago
TeamHealth Austin, TX, United StatesTeamHealth has an excellent full-time opportunity for a nurse practitioner to join our emergency department team at St. David's Main emergency department (ED) in Austin, Texas. We ask that you have a minimum of 2 years of emergency medicine experience to apply. ...
-
registered nurse manager
5 days ago
Next GenHealth Staffing Austin, United StatesJob Description · Job DescriptionJOB RESPONSIBILITIES- · Registered Nurse Manager - Surgical Services · RN MGR - OR · Full-Time · Registered Nurse candidates for the Manager position of the Surgical Services Department will have the following job responsibilities: · We are seekin ...
-
Registered Nurse Manager
1 week ago
Ascension Seton Northwest Austin, United StatesRegistered Nurse Manager - Wound Care Clinical Program · Details · * Department: Wound Care · * Schedule: 8 am-5:00 pm, Full-time · * Hospital: Dell Seton Medical Center · * Location: 1500 Red River St, Austin, TX · Benefits · Paid time off (PTO) · Various health insurance optio ...
-
registered nurse manager
5 days ago
Next GenHealth Staffing Austin, United StatesJob Description · Job Description · JOB RESPONSIBILITIES- · Registered Nurse Manager - Emergency Department · RN MGR - ED · Full-Time NIGHTS · Registered Nurse Manager candidates for the Emergency Department will have the following job responsibilities: · Supports the mission, ...
-
Emergency Nurse Manager
1 week ago
All Med Search Austin, United StatesJob Description · Job Description · As Nurse Manager in the Emergency Department, you will be responsible for overseeing both the clinical and financial outcomes of the unit. · This entails managing day-to-day operations to ensure optimal patient care, adherence to established ...
-
REGISTERED NURSE MANAGER
6 days ago
Next GenHealth Staffing Austin, United StatesJob Description · Job DescriptionJOB RESPONSIBILITIES- · Registered Nurse Manager - Surgical Trauma / Surgical Trauma Intensive Care Unit · RN MGR - SURG TRAUMA/STICU · Full-Time · Candidates for the Manager position in the Surgical Trauma Unit and STICU will have the following j ...
-
Registered Nurse Manager
6 days ago
Ascension Austin, United States Full timeDetailsDepartment: Wound Care · Schedule: 8 am-5:00 pm, Full-time · Hospital: Dell Seton Medical Center · Location: 1500 Red River St, Austin, TX · Benefits Paid time off (PTO) · Check all associated application documentation thoroughly before clicking on the apply button at the ...
-
Emergency Nurse Manager
5 days ago
All Med Search Austin, United StatesJob Description · Job DescriptionAs Nurse Manager in the Emergency Department, you will be responsible for overseeing both the clinical and financial outcomes of the unit. · This entails managing day-to-day operations to ensure optimal patient care, adherence to established prot ...
-
Registered Nurse Manager
4 days ago
Ascension Austin, TX, United States Full timeWound Care · Schedule: 8 am-5:00 pm, Full-time · Hospital: Dell Seton Medical Center · Location: 1500 Red River St, Austin, TX Benefits Paid time off (PTO) Check all associated application documentation thoroughly before clicking on the apply button at the bottom of this descr ...
Utilization Management Nurse - Austin, United States - Ethos Risk Services
Description
Job Description
Job DescriptionPosition Overview
The Utilization Review Nurse is responsible for coordinating all components of the utilization review process, which includes timely review of treatment requests for medical necessity, ensuring appropriate cost-effective treatment and promotion of best patient outcomes. The Utilization Review Nurse performs the initial clinical review, prepares an organized case summary and may issue certifications of medical necessity. When clinical requirements for medical necessity, appropriateness or effectiveness are not met and a clinical determination to certify the request cannot be made, the Utilization Review Nurse must escalate the case for peer clinical review. The Utilization Review Nurse provides clinical oversight and serves as a resource for non-clinical staff.
Roles and Responsibilities
Qualifications
Education/Licensure/Certification
Experience
Skills/Knowledge
Ethos Risk Services is an equal opportunity employer that does not discriminate on the basis of religious creed, sex, national origin, race, veteran status, disability, age, marital status, color or sexual orientation or any other characteristic protected by law.
A background check will be conducted, in accordance to the local state law and regulations.
Job Posted by ApplicantPro