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Utilization Management RN - Clinical Review 

Bring your passion to THR so we are Better Together!!

Work location: Remote 
Work hours: Full time from 6:45am to 3:15p, rotating days, weekends and holidays 
Department highlights:
Remote work
Collaborative community impact 
Team based environment 
 

Here's What You Need 
Associate's degree in Nursing required 
Bachelors degree in Nursing preferred  
5 years inpatient clinical nursing experience in an acute hospital setting required and  
1 Year Utilization Management experience 
case management and/or the application of medical necessity criteria preferred 
Texas RN upon hire required 
case management certification within 12 months of hire preferred 
MCG certification within 6 months of hire preferred 
What You Will Do 
Responsible for determining initial admission status and level of care recommendations for inpatient admissions, observation and outpatient admissions for any hospital in the THR system (requires access to all facilities in Care Connect)

Conduct initial admission review of inpatient, observation and outpatient admissions (commercial insurance, Medicare Advantage and self-pay) according to established criteria set adopted by System. Conduct initial admission review of inpatient, observation and outpatient admissions with traditional Medicare for compliance with the New IPPS rule.

Provide clinical information to payors as needed for completion of pre-certification process.

Ensure proper authorization requirements are met with each admission. Obtains or ensures acquisition of appropriate pre-certifications/authorizations from third party payers and placement to appropriate level of care prior to hospitalization or upon admission utilizing medical necessity criteria and third party payer guidelines.

Obtain or facilitate acquisition of urgent/emergent authorizations, continued stay authorizations, as needed and with compliance with all regulatory and contractual requirements.
Maintains a working knowledge of care management, utilization review changes, authorization changes, contract changes, regulatory requirements, etc.
Provide consultation to medical and nursing staff, health information management, and payers on potential issues with reimbursement of hospitalization.
Partner with hospital care transitions managers to assure effective hand-off of information related to the plan of care.
Work with bedside nurses and care team members to assure orders related to status are accurate and valid. Refer cases to physician advisor for review and determination of status or care needs.
Evaluate concurrent potential denials or payment issues and initiate communication with admitting physician to assure proper documentation for selected admission status.
Initiate and facilitate physician communication relative to the UR process when indicated. Assist and facilitate the physician peer-to-peer review process with insurance medical directors as indicated.
Determine working DRG with each initial review via CareConnect1 or other Utilization Management tool. Discusses working DRG issues as needed with Care Transition Manager.
Partner with hospital care transition managers to assure effective hand-off of information related to the plan of care.
Cover multiple THR sites adjusting practice to meet the requirements of each location.

Additional perks of being a Texas Health Employee:
Benefits include 401k, PTO, medical, dental, Paid Parental Leave, flex spending, tuition reimbursement, Student Loan Repayment Program as well as several other benefits.
At Texas Health, our people make this a great place to work every day. Our inclusive, supportive, people-first, excellence-driven culture make Texas Health a great place to work. 
A supportive, team environment with outstanding opportunities for growth.
Entity Highlights:
Texas Health Resources is one of the largest faith-based, nonprofit health care delivery systems in the United States and the largest in North Texas in terms of patients served.
Texas Health has 25 acute-care and short-stay hospitals that are owned, operated, joint-ventured or affiliated with the system. It has more than 3,800 licensed beds, more than 21,100 employees of fully owned/operated facilities plus 1,400 employees of consolidated joint ventures and counts more than 5,500 physicians with active staff privileges at its hospitals. 
We invite you to join us in furthering your career through our accomplishments and philosophy of excellence.
Learn more about our culture, benefits, and recent awards.

Do you still have questions or concerns? Feel free to email your questions to recruitment@texashealth.org.

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