DallasRecruiter Since 2001
the smart solution for Dallas jobs

RN Utilization Review - Irving

Company: Christus Health
Location: Irving
Posted on: May 22, 2019

Job Description:

DescriptionUnder the direction of the Medical Management Director, the Utilization Management (UM) Nurse is responsible for analyzing clinical information submitted by medical providers to evaluate the medical necessity, appropriateness and efficiency of the use of medical services, procedures and facilities. The UM Nurse is also expected to maintain valid, unencumbered licensure in any region that the health plan operates. The UM Nurse is responsible for clinical review of all requested services for medical necessity based upon evidence based clinical guidelines. The UM Nurse is also responsible for making phone calls to providers to address post-hospital discharge services, redirection to in network providers for appropriate steerage, durable equipment usage and utilization of other medical services and/or procedures and other telephonic follow-up as identified by the UM Nurse, the Medical Management Clinical Supervisor or Medical Management Director. The UM Nurse is responsible for telephonic availability during non-business hours to assist with medical necessity reviews for medical services, procedures or facility usage. The UM Nurse promotes quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence based clinical guidelines. The UM Nurse will also utilize the nursing process and critical thinking skills to provide oversight of services and evaluation of service options.MAJOR RESPONSIBILITIES

  • Proactively analyze information submitted by providers to make timely medical necessity review determinations based upon evidence based clinical criteria and standards within governmental and contractual guidelines
  • Identify and present cases of possible quality of care deviations, questionable admissions and prolonged lengths of stay to the Medical Director for further determination
  • Collects accurate data for system input by using correct coding of diagnoses and/or procedures
  • Processes authorization requests via phone queue according to internal departmental processes.
  • Performs selected provider calls to address post-hospital discharge services, redirection to in network providers for appropriate steerage, durable equipment usage and utilization of other medical services and/or procedures and other telephonic follow-up as identified by the UM Nurse, the Medical Management Clinical Supervisor or Medical Management Director.
  • Maintain documentation of all contacts with providers for health management activities to meet all regulatory and contractual requirements.
  • Be available for after-hours telephonic utilization review needs of providers as mandated by governmental and contractual guidelines
  • Establishes and maintain rapport with providers as well as ongoing education of providers concerning appropriate protocol.
  • Appropriately refers member for case management services who have complex case management, transition of care, disease management or other identifiable needs for coordination of the member's health care.
  • Refers member who have high dollar utilization needs to dedicated health plan staff and reinsurance provider.
  • Support cost effective care by assuring in-network resources are being used in a timely manner whenever possible. Collaborate with provider relations for out of network contracting as needed.
  • Collaborates with and maintains open communication with all other departments as appropriate and required to facilitate completion of all tasks and goals
  • Follow the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
  • Protects confidentiality of data and intellectual property; assures compliance with national health information guidelines.
  • Adhere to URAC and NCQA Standards
  • Maintain valid, unencumbered licensure in all states, regions or territories that the health plan operates.
  • Maintains all professional CEU's in compliance with State and Regulatory requirements.
  • Utilize critical thinking skills, clinical judgement and the nursing process to evaluate the need for requested clinical services, processes or facility use.
  • Communication, Collaboration and Coordination with all customers, internal and external
  • Maintain clinical competencies by attendance at selected nursing meetings and/or documentation of educational activities.
  • Attend bi-weekly departmental staff meetings.
  • Ability to sit for long periods of time.
  • Ability to organize and prioritize work to meet contractual deadlines.
  • Ability to work occasional long or irregular hours to meet business needs.
  • Good speaking ability, judgement and initiative.
  • Ability to work a flexible work schedule including evening and weekends.
  • Demonstrate organizational, time management, prioritization and team-work skills.
  • Work autonomously and be directly accountable for results.
  • Function effectively in a fluid, dynamic, and changing environment.Requirements
    • Nursing School Diploma, Associate or Bachelor's Degree in Nursing required; Bachelor's Degree preferred
    • Valid unencumbered Texas RN license
    • Excellent communication skills, (written and verbal) judgment, initiative, critical thinking and problem-solving abilities
    • Competent in Microsoft software (e.g. Word and Excel)
    • General computer knowledge and capability to use computers required.
    • Proficient typing skills.
    • Excellent telephonic customer service skills.
    • Superior clinical judgement
    • Minimum of 3-5 years experience of direct patient clinical care
    • Minimum of 1-3 years experience in a managed care environment or health plan preferred
    • Ability to work in a variety of settings with culturally-diverse communities with the ability to be culturally sensitive and appropriate
    • Knowledge of managed care principles, HMO and Risk Contracting arrangements.
    • Licensed registered nurse (current and unrestricted) in the State of Texas
    • Obtain RN licensure within 3 months of hire in any other State that health plan operates and licensure is required
    • Certification in Case Management preferred or must be achieved within two years of hire.

Keywords: Christus Health, Dallas , RN Utilization Review - Irving, Other , Irving, Texas

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Other Other Jobs


19D Cavalry Scout
Description: As a Cavalry Scout, you are the eyes and ears of the armored division. You move ahead of your division, provide reconnaissance, and report vital information back to your commanding officer. You're providing (more...)
Company: Army National Guard
Location: Waco
Posted on: 06/20/2019

Hiring OTR CDL-A Owner Operators- $10,000 Sign On Bonus [RTK]
Description: One of the Nation's Top Carriers,--Hub Group Trucking, now has a variety of driving opportunities for CDL-A owner operators. Here at Hub, we are always eager to grow and
Company: Hub Group
Location: Irving
Posted on: 06/20/2019

11C Indirect Fire Infantryman
Description: 11C Indirect Fire Infantryman Job ID: 1074953 Job Views: 20 Location: WACO, Texas, United States ZIP Code: 76707 Job Category: Infantry Posted: 05.30.2019 Age Requirements: Must be between the ages of (more...)
Company: Army National Guard
Location: Waco
Posted on: 06/20/2019


JDHuntr In-House Counsel Jobs 27681 Corporate Counsel (update), General Corporate, Irving, TX
Description: JDHuntr In-House Counsel Jobs 27681 Corporate Counsel update , General Corporate, Irving, TX To apply go to JDHuntr.com
Company: JDHuntr In-House Counsel Jobs
Location: Irving
Posted on: 06/20/2019

Representatives Needed - Telecommute
Description: Dental Plan Company, featured on 60-Minutes and in the Wall Street Journal, and Good Morning America seeks serious and positive
Company: AmeriPlan
Location: Irving
Posted on: 06/20/2019

Appointment Scheduling
Description: Are you a talented and motivated person looking for a new interesting challenge or new opportunity We
Company: Worknine
Location: Irving
Posted on: 06/20/2019

Registered Nurse (RN) Inpatient Rehab FT Day Job
Description: Baylor Scott and White Medical Center-Hillcrest Magnet Recognition ANCC As a magnet recognized hospital we set the standard ofexcellence in patient care, nursing excellence, and innovation in professionalnursing (more...)
Company: Baylor Scott & White Health
Location: Waco
Posted on: 06/20/2019

25U Signal Support Systems Specialist
Description: Communication is the pulse of Army National Guard units, and it's up to the Signal Support Systems Specialist to ensure the information keeps flowing so the military doesn't miss a beat. br br Signal (more...)
Company: Army National Guard
Location: Waco
Posted on: 06/20/2019

Medical Coder Specialties
Description: Coding Denials, ER, OBGYN, Surgical, E/M, Neurology, Neurosurgery, Oncology, Hematology, Orthopedic Pathology Multi-specialties We are hiring coders with at least three years experience in various (more...)
Company: Mommy Jobs Online
Location: Waco
Posted on: 06/20/2019

HOT TRAN$FER LEAD$ sent to your phone LIVE! BIG BUCK$! No travel!
Description: We do NOT merely save small business owners money on their merchant credit card processing fees. We ELIMINATE their fees entirely This can save your business owner
Company: Colorado Protection, LLC - zipCCfees
Location: Waco
Posted on: 06/20/2019

Log In or Create An Account

Get the latest Texas jobs by following @recnetTX on Twitter!

Dallas RSS job feeds