RN - Utilization Review - Health Plan Job

Children's Health - HMO Careers

Job Number: 52212

Location: Dallas, TX

Date Posted: 9-5-2017

Description:

Position Summary

Responsible for concurrent and retrospective audit/review and tracking of acute and sub-acute clinical data to support and improve clinical outcomes. Ensure standards of care, regulatory and accreditation requirements are met. Collaborate with physicians and/or bedside care staff to address real time opportunities.

This RN will perform work at hospital locations, and will include telephonic office & remote work.

Essential Duties and Responsibilities

  • Perform utilization review to include pre-certification, concurrent and retrospective review according to established guidelines
  • Answer utilization directed phone calls as required
  • Refer and discuss cases with the Medical Director when treatment requests do not meet medical necessity or when guidelines are not available
  • Provide coaching and guidance to other UM Nurses
  • Identify/report and refer all potential quality and fraud, waste and abuse issues
  • Conducts single case agreements as needed with non-network Providers
  • Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.

Qualifications

Education

  • Two-year Associate's degree or equivalent experience, required

Licenses & certifications

  • Current, unrestricted RN license in the State of Texas, required

Experience

  • 2+ years experience in managed care or 5+ years as an RN, required
  • Previous prior authorization/utilization management experience, preferred
  • Previous InterQual or Milliman product use highly preferred
  • ICD 9/10, CPT coding experience, preferred

Specific knowledge, skills and abilities

  • Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
  • Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
  • Meet patient and patient family needs; take responsibility for a patient's safety, satisfaction, and clinical outcomes; use appropriate interpersonal techniques to resolve difficult patient situations and regain patient confidence.
  • Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
  • Develop and use collaborative relationships to facilitate the accomplishment of work goals.
  • Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
  • Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
  • Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
  • Effectively manage one's time and resources to ensure that work is completed efficiently.
  • Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
  • Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self impose standards of excellence rather than having standards imposed.
  • Assimilate and apply new job-related information in a timely manner.
  • Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.

Physical demands

  • Duties require little or no exertion of physical effort.

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