Utilization Management/Review RN Job

Children's Health - Case Management  Careers

Job Number: 43957

Location: Dallas, TX

Date Posted: 12-3-2016

Description:

Position Summary

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

Qualifications

  • 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

Education

  • 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

Experience

  • 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.

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