RN/Registered Nurse - Utilization Management, Clinical Reviews - PRN

RN/Registered Nurse-Utilization Management, Clinical Reviews Work location: 100% remote but must live in Texas, preferably in the Dallas-Fort Worth Work hours: PRN (As needed), Weekday and weekend shifts from 6:45am -3:15pm Department highlights: • Flexible schedule • Remote work environment • Collaborative team approach Here’s What You Need Education • Associate's Degree Nursing Required Or • Bachelor's Degree Nursing Preferred Experience • 5 Years Inpatient clinical nursing experience in an acute hospital setting required and • 1 Year Utilization Management required and • Experience in case management, and/or the application of medical necessity criteria preferred Licenses and Certifications • RN - Registered Nurse Current license to practice professional nursing in the state Texas upon Hire Required And • Other Case Management certification within 12 Months Preferred And • Other MCG certification within 6 Months preferred Skills • Requires interpersonal, analytic, and critical thinking skills for problem solving and decision making. Broad and intimate knowledge of reimbursement and regulatory requirements. Decisive judgment and the ability to work with minimal supervision. • Must be able to work in a fast-paced environment requiring adaptability, flexibility, and independence while demonstrating high professional standard, leadership, and team membership skills. • Must be well organized and have the ability to prioritize and handle multiple tasks efficiently and independently. • Have demonstrated ability to initiate and follow through with multiple projects. • Proficient computer skills with experience in: MS Office, internet navigation, clinically-based software, and financially-based software. What You Will Do • Responsible for determining initial admission status and level of care recommendations for inpatient admissions, observation and outpatient admissions for any hospital in the THR system (requires access to all facilities in Care Connect) • Conduct initial admission review of inpatient, observation and outpatient admissions (commercial insurance, Medicare Advantage and self-pay) according to established criteria set adopted by System. Conduct initial admission review of inpatient, observation and outpatient admissions with traditional Medicare for compliance with the New IPPS rule. • Provide clinical information to payors as needed for completion of pre-certification process. • Ensure proper authorization requirements are met with each admission. Obtains or ensures acquisition of appropriate pre-certifications/authorizations from third party payers and placement to appropriate level of care prior to hospitalization or upon admission utilizing medical necessity criteria and third-party payer guidelines. • Obtain or facilitate acquisition of urgent/emergent authorizations, continued stay authorizations, as needed and with compliance with all regulatory and contractual requirements. 40% • Provide consultation to medical and nursing staff, health information management, and payers on potential issues with reimbursement of hospitalization. • Evaluate concurrent potential denials or payment issues and initiate communication with admitting physician to assure proper documentation for selected admission status. • Collaborate and communicate with payer via phone, fax or computer system per payer contract. • Initiate and facilitate physician communication relative to the UR process when indicated. Assist and facilitate the physician peer-to-peer review process with insurance medical directors as indicated. • Communicate payer issues and medical necessity concerns with members of the health care team. • Determine working DRG with each initial review via CareConnect1 or other Utilization Management tool. Discusses working DRG issues as needed with Care Transition Manager 30% Additional perks of being a Texas Health employee • Delivery of high quality of patient care through nursing education, nursing research and innovations in nursing practice. • Strong Unit Based Council (UBC). • A supportive, team environment with outstanding opportunities for growth • Explore our Texas Health careers site for info like Benefits, Job Listings by Category, recent Awards we’ve won and more. At Texas Health Resources, our mission is “to improve the health of the people in the communities we serve”. We are one of the largest faith-based, nonprofit health systems in the United States with a team of more than 23,000 employees of wholly owned/operated facilities plus 2,200 employees of consolidated joint ventures in the greater Dallas Fort Worth area. Our career growth and professional development opportunities are top-notch and our benefits are equally outstanding. Do you still have questions or concerns? Feel free to email your questions to [email protected]. #LI-LD1 Apply Job!