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Utilization Review RN

Company: Baylor Scott White Health
Location: Dallas
Posted on: June 14, 2018

Job Description:

Utilization Review RN-(18004787)
Description
The Utilization Review Nurse is a registered nurse who provides clinical review against standard criteria for the purpose of evaluating medical necessity for hospitalization, regardless of payor type. Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. Provides ongoing communication with health plan utilization departments regarding medical necessity for prospective, concurrent, and retrospective reviews. Intervenes when potential denials are determined and facilitates appeals when concurrent denials are received. Partners with physicians related to appropriateness of admission and the prevention of denials. The essential functions of the Utilization Review RN include the following:
Perform initial, concurrent, discharge and retrospective reviews on all patients.

Review current charts for appropriateness and correct admission status (inpatient, observation, bedded outpatients).Communicate directly with insurance companies and/or payor to obtain admission and continued stay certification or recertification.

Facilitate peer to peer appeal for concurrent denials.

Fax reviews per policy and as needed to stay current on certified days.

Collaborate with Care Coordination Medical Director on patients not meeting criteria and informs Clinical Resource Manager/Director as needed.

Assign a working diagnosis related groups (DRGs) on all patients.

Communicate with attending physician regarding patients who do not meet criteria to identify additional documentation needs or potential status change.

Communicate identified patients who do not meet criteria to Care Coordination for discharge planning.

Communicate problems or trends with insurance companies to Clinical Resource Manager/Director.

Perform chart analysis on quality surveillance and special studies as requested.


The ideal Utilization Review RN candidate will have written and verbal communication skills to request information, critical thinking skills to review and apply medical necessity criteria.
Location/Facility' Dallas, TX
For more information on the facility, please click ourLocationslink.

Specialty/Department/Practice ' Utilization review

Shift/Schedule' Full time

Benefits 'Our competitive benefits package includes*:

Immediate eligibility for health and welfare benefits

401(k) savings plan with dollar-for-dollar match up to 5%

Tuition Reimbursement

PTO accrual beginning Day 1




*Note: Benefits may vary based upon position type and/or level.
Baylor Scott & White Health (BSWH)is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation's exemplary health care organizations. Ourmissionis to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it's accepting a calling!
Qualifications
Bachelor's degree or equivalent experience required

Registered Nurse License required

3+ years of related work experience required



Primary Location:US-Texas-Dallas
Work Locations:Bryan Tower - 27th Floor
2001 Bryan St
Dallas75201

Job:Utilization Review
Organization:Corporate
Shift:Day Job
Job Type:Standard
Job Posting:Apr 22, 2018, 3:44:17 AM

Keywords: Baylor Scott White Health, Dallas, Utilization Review RN, Healthcare, Dallas, Texas

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