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Utilization Management RN - Manager

Company: Children's Medical Center Dallas
Location: Dallas
Posted on: January 27, 2023

Job Description:

Utilization Management RNThis position is remote (may require some meetings onsite in Dallas)



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.


* Accountable for current knowledge of utilization management responsibilities, including: payer information; business rules; regulatory guidelines; and policies and procedures.
* Performs initial, concurrent, discharge, and retrospective reviews on assigned caseload. Reviews inpatient medical necessity criteria utilizing Indicia or Interqual, CHST clinical pathways, and clinical knowledge to determine appropriateness of admission, level of care, and continued stay.
* 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.
* 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.
* Maintains productivity and optimum case load, delegating appropriately to maximize skills set, productivity and effectiveness.
* Collaborates with Patient Access Services as it relates to inpatient authorization, predetermination, pre/prior authorization, and status changes.
* Communicates with Commercial or MMC (Medicaid Managed Care) payers to certify inpatient days as required. Utilizes various methods to obtain necessary information: telephone, fax, secure email, secure web portal. Removing completed cases from the Midas worklist.
* Maintain accurate documentation of all communication and interventions in EMR.
* Escalate payer problems to UM RN II or Denials Management Specialist
* Proactively intervenes with medical necessity, or level of care denials by exercising all real-time options to overturn decision. Actions include, but not limited to,
* requesting expedited appeal, use of third party Physician Advisor, facilitation of peer to peer with CHST Physician.
* Identifies issues and strategies to modify and/or enhance the utilization management program.
* Advances clinical expertise through attendance at in-hours education opportunities, reading journals, and attendance at conferences.
* Attends department/program meetings regularly.
* 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

Other information:


* At least 4 years clinical nursing experience. For those employees hired after 4/1/2022 experience must be in the following areas: CCBD (Oncology), NICU, PICU, Heart Center (Cardiology, Pulmonary and/or Emergency Department) Required
* At least 1 year Utilization Review or Case Management experience Preferred
* Previous experience with Interqual or Milliman Preferred


* BSN required


* Registered Nurse Required
* Accredited Case Manager (ACM) or Certified Case Manager (CCM) certification Preferred

About us

Children's Health values the role each member of our team plays in helping us make life better for children. We employ more than 7,500 people and provide rewarding career opportunities that help them reach their highest potential.

We also hold Magnet recognition from the American Nurses Credentialing Center for nursing excellence, we serve as the primary pediatric teaching facility for---the University of Texas Southwestern Medical Center, and we are widely recognized for delivering high quality care.

Children's Health has also been named one of the 150 Top Places to Work in Healthcare by Becker's Healthcare for nine consecutive years.

We invite you to learn more about Children's Health.


Children's Health offers competitive pay, a comprehensive benefits program and opportunities for learning and career development. We promote a diverse and inclusive workplace, and our team members have a voice in their work through surveys and town halls.

We invite you to learn more about Children's Health.

Keywords: Children's Medical Center Dallas, Dallas , Utilization Management RN - Manager, Executive , Dallas, Texas

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