RN Utilization Review - Irving
Company: Christus Health
Posted on: May 22, 2019
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
- 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
- Be available for after-hours telephonic utilization review
needs of providers as mandated by governmental and contractual
- Establishes and maintain rapport with providers as well as
ongoing education of providers concerning appropriate
- 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
- 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
- Protects confidentiality of data and intellectual property;
assures compliance with national health information
- 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
- 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
- Attend bi-weekly departmental staff meetings.
- Ability to sit for long periods of time.
- Ability to organize and prioritize work to meet contractual
- Ability to work occasional long or irregular hours to meet
- Good speaking ability, judgement and initiative.
- Ability to work a flexible work schedule including evening and
- Demonstrate organizational, time management, prioritization and
- Work autonomously and be directly accountable for results.
- Function effectively in a fluid, dynamic, and changing
- 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
- Proficient typing skills.
- Excellent telephonic customer service skills.
- Superior clinical judgement
- Minimum of 3-5 years experience of direct patient clinical
- 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
- 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
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