Healthcare Utilization Review Nurse II (Hiring Immediately)
Company: CHRISTUS Health
Location: Tyler
Posted on: October 26, 2024
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Job Description:
Description _Summary:_ The Utilization Management Nurse II is
responsible for determining the clinical appropriateness of care
provided to patients and ensuring proper hospital resource
utilization of services. This Nurse is responsible for performing a
variety of pre-admission, concurrent, and retrospective UM related
reviews and functions. They must competently and accurately utilize
approved screening criteria (InterQualMCGCenters for Medicare and
Medicaid Services ---CMS--- Inpatient List). They effectively and
efficiently manage a diverse workload in a fast-paced, rapidly
changing regulatory environment and are responsible for maintaining
current and accurate knowledge regarding commercial and government
payors and Joint Commission regulations and guidelines related to
UM. This Nurse effectively communicates with internal and external
clinical professionals, efficiently organizes the financial
insurance care of the patients, and relays clinical data to
insurance providers and vendors to obtain approved certification
for services. The Utilization Management Nurse collaborates as
necessary with other members of the health care team to ensure the
above according to the mission of CHRISTUS. _Responsibilities:_
Meets expectations of the applicable OneCHRISTUS Competencies:
Leader of Self, Leader of Others, or Leader of Leaders. Applies
demonstrated clinical competency and judgment in order to perform
comprehensive assessments of clinical information and treatment
plans and apply medical necessity criteria in order to determine
the appropriate level of care. ResourceUtilization Management
appropriateness: Assess assigned patient population for medical
necessity, level of care, and appropriateness of setting and
services. Utilizes MCGInterQual Care Guidelines andor health
system-approved tools to track impact and variance. Uses
appropriate criteria sets for admission reviews, continued stay
reviews, outlier reviews, and clinical appropriateness
recommendations. Coordinate and facilitate correct identification
of patient status. Analyze the quality and comprehensiveness of
documentation and collaborate with the physician and treatment team
to obtain documentation needed to support the level of care.
Facilitates joint decision-making with the interdisciplinary team
regarding any changes in the patient status andor negative outcomes
in patient responses. Demonstrates, maintains, and applies current
knowledge of regulatory requirements relative to the work process
in order to ensure compliance, i. e. IMM, Code 44. Demonstrate
adherence to the CORE values of CHRISTUS. Utilize independent scope
of practice to identify, evaluate and provide utilization review
services for patients and analyze information supplied by
physicians (or other clinical staff) to make timely review
determinations, based on appropriate criteria and standards. Take
appropriate follow-up action when established criteria for
utilization of services are not met. Proactively refer cases to the
physician advisor for medical necessity reviews, peer-to-peer
reviews, and denial avoidance. Effectively collaborate with the
Interdisciplinary team including the Physician Advisor for
secondary reviews. Proactively review patients at the point of
entry, prior to admission, to determine the medical necessity of a
requested hospitalization and the appropriate level of care or
placement for the patient. Review surgery schedule to ensure
planned surgeries are ordered in the appropriate status and that
necessary authorization has been obtained as required by the payor
or regulatory guidance (i. e., CMS Inpatient Only List, Payor Prior
Authorization matrix, etc.) Regularly review patients who are in
the hospital in Observation status to determine if the patient is
appropriate for discharge or if conversion to inpatient status is
appropriate. Proactively identify and resolve issues regarding
clinical appropriateness recommendations, coverage, and potential
or actual payor denials. Maintain consistent communication and
exchange of information with payors as per payor or regulatory
requirements to coordinate certification of hospital services.
Coordinate and facilitate patient care progression throughout the
continuum and communicate and document to support medical necessity
at each level of care. Evaluate care administered by the
interdisciplinary health care team and advocate for standards of
practice. Analyze assessment data to identify potential problems
and formulate goalsoutcomes. Follows the CHRISTUS Guidelines
related to the Health Insurance Portability and Accountability ACT
(HIPPA) designed to prevent or detect unauthorized disclosure of
Protected Health Information (PHI). Attend scheduled department
staff meetings andor interdepartmental meetings as appropriate.
Possesses and demonstrates technology literacy and the ability to
work in multiple technology systems. Act as a catalyst for change
in the organization; respond to change with flexibility and
adaptability; demonstrate the ability to work together for change.
Translate strategies into action steps; monitor progress and
achieve results. Demonstrate the confidence, drive, and ability to
face and overcome challenges and obstacles to achieve
organizational goals. Demonstrate competence to perform assigned
responsibilities in a manner that meets the population-specific and
developmental needs of patients served by the department. Possess
negotiating skills that support the ability to interact with
physicians, nursing staff, administrative staff, discharge
planners, and payers. Excellent verbal and written communication
skills, knowledge of clinical protocol, normative data, and health
benefit plans, particularly coverage and limitation clauses. Must
adjust to frequently changing workloads and frequent interruptions.
May be asked to work overtime or take calls. May be asked to travel
to other facilities to assist as needed. Actively participates in
MultidisciplinaryPatient Care Progression Rounds. Escalates cases
as appropriate and per policy to Physician Advisors andor CM
Director. Documents in the medical record per regulatory and
department guidelines. May be asked to assist with special
projects. May serve as a preceptor or orienter to new associates.
Assumes responsibility for professional growth and development.
Familiarity with criteria sets including InterQual and MCG
preferred. Must have excellent verbal and written communication and
ability to interact with diverse populations. Must have critical
and analytical thinking skills. Must have demonstrated clinical
competency. Must have the ability to Multitask and to function in a
stressful and fast-paced environment. Must have working knowledge
of discharge planning, utilization management, case management,
performance improvement, and managed care reimbursement. Must have
an understanding of pre-acute and post-acute levels of care and
community resources. Must have the ability to work independently
and exercise sound judgment in interactions with physicians,
payors, patients, and their families. Must have an understanding of
internal and external resources and knowledge of available
community resources. Other duties as assigned. _Job Requirements:_
EducationSkills Graduate of an accredited School of Nursing OR
demonstrated success in the Utilization Management Nurse I role for
at least five years at CHRISTUS Health on top of required
experience in lieu of education required. Experience Two or more
years of clinical experience with at least one year in the acute
care setting OR demonstrated success as Utilization Management
Nurse I role at CHRISTUS Health required. Licenses, Registrations,
or Certifications RN License in state of employment or compact
required. LPN or LVN license accepted for associates with 5 years
of demonstrated success and experience in the Utilization
Management Nurse I role at CHRISTUS Health. Certification in Case
Management preferred. BLS preferred. _Work Schedule:_ 8AM - 5PM
Monday-Friday _Work Type:_ Full Time EEO is the law - click below
for more information: We endeavor to make this site accessible to
any and all users. If you would like to contact us regarding the
accessibility of our website or need assistance completing the
application process, please contact us at (844) 257-6925.
Keywords: CHRISTUS Health, Longview , Healthcare Utilization Review Nurse II (Hiring Immediately), Healthcare , Tyler, Texas
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