Welcome page Returning Candidate? Log back in! Utilization Review Nurse - Transition in Care Facility Josie Roberts Admin Building Job Locations US-TX-Houston Category RN - Other Position Type Full-Time Department Transition in Care Shift 1st - Day Overview

At Houston Methodist, the Utilization Review Nurse (URN) position is a licensed registered nurse (RN) who comprehensively conducts point of entry and concurrent medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, payer guidelines, CMS, and other state agencies. This position prospectively or concurrently determines the appropriateness of inpatient or observation services following review of relevant medical documentation, medical guidelines, and insurance benefits and communicates information to payers in accordance with contractual obligations. The URN position serves as a resource to the physicians and provides education and information on resource utilization and national and local coverage determinations (LCDs & NCDs). This position collaborates with case management in the development and implementation of the plan of care and ensures prompt notification of any denials to the appropriate case manager, denials, and pre-bill team members, as well as management.

Houston Methodist Standard

HOUSTON METHODIST EXPERIENCE EXPECTATIONS

Provide personalized care and service by consistently demonstrating our I CARE values:INTEGRITY: We are honest and ethical in all we say and do.COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.ACCOUNTABILITY: We hold ourselves accountable for all our actions.RESPECT: We treat every individual as a person of worth, dignity, and value.EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.Practices the Caring and Serving ModelDelivers personalized service using HM Service StandardsProvides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experienceInvolves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given jobActively supports the organization's vision, fulfills the mission and abides by the I CARE values Responsibilities

PEOPLE ESSENTIAL FUNCTIONS

Establishes and maintains effective professional working relationships with patients, families, interdisciplinary team members, payers, and external case managers; listens and responds to the ideas of others.Collaborates with the access management team to ensure accurate and complete clinical and payer information. Educates members of the patient's healthcare team on the appropriate access to and use of various levels of care.Contributes towards improvement of department scores for employee engagement, i.e. peer-to-peer accountability.

SERVICE ESSENTIAL FUNCTIONS

Pro-actively participates as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patient's preference, reason for admission, and availability of resources. Participates in daily Care Coordination Rounds and identifies and communicates barriers to efficient utilization.Reviews H&Ps and admitting orders of all direct, transfer, and emergency care patients designated for admission to ensure compliance with CMS guidelines regarding appropriateness of level of care.Identifies potentially unnecessary services and care delivery settings and recommends alternatives, if appropriate, by analyzing clinical protocols.Escalates appropriate cases to the Physician Advisor (or services) for appropriate second level review, peer-peer discussions, and payer denial- appeal needs. Consults with physician advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

Participates in quality improvement activities as stewards for resource utilization as it pertains to medical necessity and level of care. Promotes medical documentation that accurately reflects intensity of services, quality and safety indicators and patient's need to continue stay.Promotes the use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care. Identifies areas for improvement based on an understanding of evidence-based practice/performance improvement projects based on these observations.Identifies and records episodes of preventable delays or avoidable days due to failure of the progression of the care process

FINANCE ESSENTIAL FUNCTIONS

Contributes to meeting department financial targets, with a focus on appropriate utilization and denial prevention. Utilizes resources with cost effectiveness and value creation in mind. Self-motivated to independently manage time effectively and prioritize daily tasks, assisting coworkers as needed.Performs review for medical necessity of admission, continued stay and resource use, appropriate level of care, and program compliance using evidence-based, nationally recognized guidelines. Manages assigned patients and communicates and collaborates with the case manager to assist with appropriate interventions to avoid denial of payment.Collaborates with the revenue cycle regarding any claim issues or concerns that may require clinical review during the pre-bill, audit, or appeal process.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

Identifies and presents areas for improvement in patient care or department operations and offers solutions by participating in department projects and activities.Seeks opportunities to identify self-development needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an ongoing basis.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

Qualifications

EDUCATION

Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations sectionBachelor's degree preferred

WORK EXPERIENCE

Three years of hospital clinical nursing experience, which includes two years in case management License/Certification

LICENSES AND CERTIFICATIONS - REQUIRED

RN - Registered Nurse - Texas State Licensure -- Compact Licensure - Must obtain permanent Texas license within 60 days (if establishing Texas residency) KSA/ Supplemental Data

KNOWLEDGE, SKILLS, AND ABILITIES

Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluationsSufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or securityAbility to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principlesProgressive knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and knowledge of local and national coverage determinationsRecent work experience in a hospital or insurance company providing utilization review servicesKnowledge of Medicare, Medicaid, and Managed Care requirementsProgressive knowledge of community resources, health care financial and payer requirements/issues, and eligibility for state, local, and federal programsProgressive knowledge of utilization management, case management, performance improvement, and managed care reimbursementAbility to work independently and exercise sound judgment in interactions with physicians, payers, and health care team membersStrong assessment, organizational, and problem-solving skillsMaintains level of professional contributions as defined in Career Path programUnderstands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44)

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

Uniform NoScrubs NoBusiness professional YesOther (department approved) No

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below.

On Call* Yes

TRAVEL**
**Travel specifications may vary by department**

May require travel within the Houston Metropolitan area YesMay require travel outside Houston Metropolitan area No Company Profile

Houston Methodist (HM) is one of the nation’s leading health systems and academic medical centers.  HM consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the heart of the Texas Medical Center, and seven community hospitals throughout the greater Houston metropolitan area.  HM also includes an academic institute, a comprehensive residency program, a global business division, numerous physician practices and several free-standing emergency rooms and outpatient facilities.  Overall, HM employs over 25,000 employees.   Houston Methodist is supported by a wide variety of business functions that operate at the system level to help enable clinical departments to provide the best patient care and service in a spiritual environment.

 

In 2019 Houston Methodist and its physicians treat more than 6,333 international patients from more than 76 countries. Houston Methodist Global Health Care Services’ consulting and education divisions also provide advisory services and training and development to health care organizations around the world.

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Houston Methodist is an Equal Opportunity Employer.
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