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Job Title & Specialty Area: Prospective Review RN

Department: Utilization Management

Location: Children's Health- Trinity Towers

Shift: Full-time, Monday through Friday

Job Type: Remote, with some occasional onsite attendance required

Why Children's Health?

At Children's Health, our mission is to Make Life Better for Children, and we recognize that their health plays a crucial role in achieving this goal.

Through our cutting-edge treatments and affiliation with UT Southwestern, we strive to deliver an extraordinary patient and family experience, ensuring that every moment, big or small, contributes to their overall well-being.

Our dedication to promoting children's health extends beyond our organization and encompasses the broader community. Together, we can make a significant difference in the lives of children and contribute to a brighter and healthier future for all.

Summary:
The Prospective Review Nurse is responsible for conducting utilization review of scheduled inpatient services requested by Physician/Provider in the prior authorization process. This role will support Ambulatory clinics and Patient Access Service areas; assisting in reviewing medical records for appropriate reimbursement of medically necessary services meeting contractual payor requirements and utilizing nationally recognized criteria guidelines. This includes communication with clinic administrative staff and Physicians/ Providers admitting patients to a Children's Health System of Texas (CHST) facility, and collaboration with the Physician Advisor during the review process. The Prospective Review Nurse will work collaboratively with Utilization Management Nurses to monitor and resolve quality opportunities for appropriate authorization; and Denials Management Specialist to analyze denial data, propose and execute improvements to increase compliance of appropriate authorization process.

Responsibilities:
* In collaboration with Patient Access Services, Ambulatory clinics and UM leadership planning and execution of communication to various facilities, developing workflow processes for referring future inpatient encounters and setting timeframes for processing, initial/ongoing meetings for education of nurse supporting role and established processes, works collaboratively with UM Denials Specialist to identify denial trends and provides feedback to affected areas, collaboratively develops action plans to mitigate denial issues, assist/serve as content expert and resource.
* Develop written detailed Letter of Medical Necessity (LOMN) by compiling the patient's comorbidities, PMH, service request(s), applicable CPT codes and rationale based on the conducted clinical research for the recommended pre-service status and submit to the payor for an Inpatient authorization.
* Review of evidenced- based research articles for medications and procedures to support rationale for appropriate pre- admission status and reference/include articles in LOMN
* Collaborate and provide education to specialty clinics on scheduling procedures with the correct CPT codes and ensuring that the intent of the procedure is appropriately documented in the EMR.
* Apply understanding of complex medical comorbidities and disease processes upon review of clinical records for prescheduled procedures
* Before completion of payer prior authorization, ensures prior authorization/ prospective review requests are conducted utilizing MCG or Indicia, CHST clinical pathways, and clinical knowledge to determine appropriateness of admission, and level of care. Collaborate with appropriate medical and professional staff on an alternative level of care when appropriate. Assists CHST non-medical staff with issues that require clinical interpretation or explanation; serves as the liaison between Physician/ Providers, or payers for medical knowledge base.
* Utilizes EPIC for chart review to obtain pertinent clinical information supporting appropriate level of care in the prior authorization process. Interacts with medical and professional staff to obtain clinical documentation in EPIC which accurately supports medical necessity.
* Other job duties as assigned

How You'll Be Successful:

WORK EXPERIENCE
* At least 5 years clinical nursing experience (pediatrics preferred) Required
* At least 1 year Utilization Review or Case Management experience Required
* Appeals experience Preferred
* Experience with InterQual or Milliman Preferred
EDUCATION
* Four-year Bachelor's degree or equivalent experience Required
LICENSES AND CERTIFICATIONS
* Registered Nurse Required
* Accredited Case Manager (ACM) or Certified Case Manager (CCM) certification Preferred

A Place Where You Belong

We put our people first. We welcome, value, and respect the beliefs, identities and experiences of our patients and colleagues. We are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children's Health a place where everyone can contribute.

Holistic Benefits - How We'll Care for You:

Employee portion of medical plan premiums are covered after 3 years.

4%-10% employee savings plan match based on tenure

Paid Parental Leave (up to 12 weeks)

Caregiver Leave

Adoption and surrogacy reimbursement

As an equal opportunity employer, Children's Health does not discriminate against employees or applicants because of race, color, religion, sex, gender identity and expression, sexual orientation, age, national origin, veteran or military status, disability, or genetic information or any other Federal or State legally protected status or class. This applies to all aspects of the employer-employee relationship including but not limited to recruitment, hiring, promotion, transfer pay, training, discipline, workforce adjustments, termination, employee benefits, and any other employment-related activity.