The Utilization Management Nurse is responsible for determining and managing medical necessity of acute inpatient admissions utilizing clinical criteria. This includes communication with the Physician's admitting patients to a Children's Health System of Texas (CHST) facility and collaboration with the Physician Advisor during the review process.
Essential Duties and Responsibilities
- Requires in-depth professional knowledge and practical/applied expertise in own discipline and basic knowledge of related disciplines within the broader professional field
- Has knowledge of best practices and how own area integrates with others; demonstrates awareness of the industry, including regulatory, evolving customer demands, and the factors that differentiate the organization in the market
- Acts as a resource for colleagues with less experience; may lead projects with manageable risks and resource requirements
- Solves complex problems and takes a new perspective on existing solutions; exercises judgment based on the analysis of multiple sources of information
- Impacts a range of customer, operational, project or service activities within own team and other related teams; works within broad guidelines and policies
- Works independently, receives minimal guidance
- Explains difficult or sensitive information; works to build consensus
- Performs initial review of acute care patients utilizing medical necessity criteria, CHST clinical pathways, and clinical knowledge to determine appropriate level of care within 12 hours of admission.
- Performs concurrent review of all patients admitted for an observation period to determine appropriate level of care daily
- Performs discharge review of all patients discharged within 72 hours of inpatient admission
- Combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided.
- Through continuous assessments, problem identification and education facilitates the quality of health care delivery in the most cost effective manner.
- Leverages clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness.
- Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health-care facility to comply with government and insurance company reimbursement policies: Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.
- Maintains a level of productivity and quality consistent with: complexity of the assignment; facility policies and guidelines; established principles, ethics and standards of practice of professional nursing;
- Other job duties as assigned
- Four-year Bachelor's degree or equivalent experience, required
Licenses & certifications
- Registered Nurse, required
- Accredited Case Manager (ACM) or Certified Case Manager (CCM) certification, preferred
- Five (5) years clinical nursing (pediatrics preferred), required
- Minimum 1 year Utilization Review or Case Management experience, required
- Appeals experience, preferred
- Previous experience with Interqual or Milliman, preferred
Specific knowledge, skills, and abilities
- Effectively keyboard at least 55 words per minute
- 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.
- 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.