Utilization Review Nurse - Part Time
Company: UT Southwestern Medical Center
Posted on: March 28, 2020
This position is security-sensitive and subject to Texas Education
Code 51.215, which authorizes UT Southwestern to obtain criminal
history record information.
Conduct medical certification review for medical necessity for
acute care facility and services. Use nationally recognized,
evidence-based guidelines approved by medical staff to recommend
level of care to the physician and serve as a resource to the
medical staff on issues related to admission qualifications,
resource utilization, national and local coverage determinations
and documentation requirements.
Experience and Education
Graduate of accredited nursing program and holds an active
unrestricted RN license in the State of Texas.
RN with 6 years of clinical experience and a minimum of 3 years
recent UR experience, acute care preferred.
Expert knowledge of InterQual Level of Care Criteria and knowledge
of local and national coverage determinations.
Basic computer skills and knowledge.
Prior exprience with Epic
General good health and stress coping ability.
Full mobility and ability to participate in vigorous activity.
Ability to speak and hear, to allow discussions with physicians,
patients and other members of the healthcare team.
Possess near vision acuity for accurate reading of computer screens
and recording on patient charts.
BLS certification required for employees that work on-site. This is
not required for the employees that telecommute from home.
- Collaborates with the access management team to provide
accurate and complete clinical information in order to obtain
- Conducts inpatient admission review for Medicare and Medicaid
beneficiaries as we1l as private insurance members and self-pay
patients based on evidence-based guidelines.
- Admission reviews are done concurrently at the point of entry
in collaboration with ED and admitting physician and the
cooperation with the access management team to determine the
appropriateness of hospital level of care.
- Confers with admitting physicians when documentation does not
appear to support hospital level of care and offers suggestions for
clarity and completeness.
- Uses InterQual Level of Care Criteria for appropriateness for
inpatient level of care or observation services based on physician
documentation, H&P, treatment plan, potential risks, and basis
for expectation of a two-midnight stay.
- Keeps current on all Federal, State and local regulatory
changes that affect delivery or reimbursement of acute care
services within the scope of Utilization Management. Uses knowledge
of national and local coverage determinations to appropriately
- Proactively collaborates with admitting physician to provide
coaching on accurate level of care determination at
- Consistently identifies and records information on any
progression-of-care/patient flow barriers.
- Actively participates in daily huddles, multidisciplinary
rounds and patient care conferences to maintain knowledge about
intensity of services and the progression of care.
- Identifies and records episodes of preventable delays or
avoidable days due to failure of progression-of-care
- Educates members of the patient s care team on the appropriate
access to and use of various levels of care.
- Promotes use of evidence-based protocols and/or order sets to
influence high-quality and cost-effective care.
- Serves as a resource person to physicians, care coordinators,
physician offices and billing office for coverage and compliance
- Works closely with decision support staff to review resource
utilization data and trends to identify outliers who may benefit
from real-time coaching to improve outcomes.
- Completes all reviews within department established policies
and best practice standards. Meets department quality standards as
established for the department, ie: Inter-rater Reliability audits,
completing all initial reviews within established time frames,
completes concurrent and discharge reviews to meet department and
Knowledge, Skills, & Abilities
- Identifies avoidable days (quality and risk issues), makes
appropriate referrals. Confers with Manager and/or Medical Director
- Actively participates in the department s performance
- Identifies the need for professional growth and seeks out
appropriate development opportunities.
Evaluates outcomes data to identify trends and areas for
improvement (i.e. avoidable days, denial information)
Work is performed with the ability to lift up to 20 pounds maximum
with frequent lifting and/or carrying of objects weighing up to 10
pounds. Even though the weight lifted may only be a negligible
amount, a job is in this category when it requires walking or
standing to a significant degree.
Any qualifications to be considered as equivalents in lieu of
stated minimums require prior approval of the Vice President for
Human Resources Administration, or his/her designee.
UT Southwestern Medical Center is committed to an educational and
working environment that provides equal opportunity to all members
of the University community. In accordance with federal and state
law, the University prohibits unlawful discrimination, including
harassment, on the basis of: race; color; religion; national
origin; sex; including sexual harassment; age; disability; genetic
information; citizenship status; and protected veteran status. In
addition, it is UT Southwestern policy to prohibit discrimination
on the basis of sexual orientation, gender identity, or gender
Associated topics: asn, care, ccu, coronary, mhb, nurse, nurse
clinical, psychiatric, staff nurse, tcu
Keywords: UT Southwestern Medical Center, Dallas , Utilization Review Nurse - Part Time, Healthcare , Dallas, Texas
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