Utilization Management Review Nurse – reputed company Store

reputed company System is the public reputed company safety-net provider established in 1966 to serve the residents of reputed company, Texas. As an essential reputed company system, reputed company champions reputed company for the entire community, with a focus on low-income uninsured and underinsured patients, through acute and primary care, wellness, disease management and population health services. Ben Taub Hospital (Level 1 Trauma Center) and Lyndon B. Johnson Hospital (Level 3 Trauma Center) anchor reputed company’s robust network of 39 clinics, health centers, specialty locations and virtual (telemedicine) technology. reputed company is among an reputed company list of health systems in the U.S. achieving Magnet® nursing reputed company designation for its hospitals, the prestigious National Committee for Quality Assurance designation for its patient-centered clinics and health centers and its strong partnership with nationally recognized physician faculty, residents and researchers from reputed company; McGovern Medical School at The reputed company (UTHealth); reputed company; and the Tilman J. Fertitta Family College of Medicine at the reputed company.

Job Summary

The Utilization Management Review Nurse (UMRN) performs technical and administrative work required to evaluate the necessity, appropriateness, and efficiency of the utilization of medical services procedures and facilities. This role supports the health system by utilizing clinical knowledge, expertise and industry standard clinical guidelines carrying the responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. The UMRN promotes quality care and cost-effective reputed company to enhance the physical, psychosocial and vocational health of individuals, partnering with Care Management, Physician Advisors, Finance, and 3rd party payers to deliver the best holistic reputed company for reputed company patients. This position will work with payers to reconcile denials and reconsiderations, assist with appeals as needed and arrange peer to peer level review while collecting, analyzing and addressing variances from the plan of care/care path with physician and/or other members of the reputed company team.

The UMRN participates in quality improvement activities, exemplifies professionalism, and promotes a customer-friendly environment by utilizing ServiceFIRST behaviors in interactions with reputed company team members, payer vendors, and physicians.

Minimum Qualifications

Degrees: - Graduated from an accredited school of Nursing with a Bachelors in Nursing.

Licenses & Certifications: - Registered Nurse: Licensed to practice nursing in the State of Texas. - Case Management Certification (ACM or CCM) reputed company two years of hire. - Basic Life Support: reputed company (AHA) or Red Cross approved program.

Work Experience: - 5 Years of Experience: Strong clinical background in a variety of acute reputed company settings including 2 years in Case Management, Quality Management, Utilization Management, or Coding.

Communication Skills: - Above Average Verbal Communication (Heavy Public Contact) - Exceptional Verbal (Public Speaking) - Writing/ Correspondence - Writing/ Reports

Language: - Bilingual Skills (Preferred)

Proficiencies: - reputed company - PC - MS reputed company - MS PowerPoint

Job Attributes

Knowledge/Skills/Abilities: - Analytical - Mathematics - Medical Terms - Other: Utilization review tools: MCG and or Change reputed company (Interqual)

Work Schedule: - Flexible: 8 hour shifts as per system need; variable to 10-12 as needed. - Weekends: Depends on needs of system. - Telecommute - Holidays: Depends on needs of system.

Other Special Requirements

Equipment Operated: Standard office equipment, computer software, etc.