Utilization Review Rn Jobs in Fort Worth, TX (NOW HIRING)

North Central Surgical Center is a highly successful, Baylor Scott & White affiliated hospital located in Dallas, TX.  We partner with the very best team members and medical staff in the area.  We are a surgical focused hospital that performs over 12,000 procedures per year. 

FACTS ABOUT NORTH CENTRAL: Opened in 2005, 14 Operating Rooms and 30 Medical/Surgical Patient Rooms.  We are conveniently Located at Walnut Hill & 75 in the prestigious NorthPark area Specialties include: Orthopedics, Spine, General Surgery, Pain Management, Urology, GI/Endoscopy, Plastic, and Podiatry surgeries. Managed by United Surgical Partners International & Joint Commission Accredited

Under the direction of the Chief Financial Officer, the Case Manager is responsible for facilitating patient progression through the continuum of care, from pre-admission through discharge. This role provides feedback to payors regarding clinical status, secures authorization for additional days of stay, and monitors quality standards in alignment with the hospital’s Performance Improvement Plan and Medical Staff Quality Indicators. The Case Manager assesses discharge planning needs, monitors resource utilization, and addresses psychosocial and educational needs to ensure optimal patient outcomes. Additionally, this position assists in data collection for quality trending, performs infection control surveillance, and serves as a patient advocate, helping to resolve care-related concerns effectively and compassionately.

Principle Duties and Responsibilities:

Patient Care Coordination:

• Coordinate with multidisciplinary teams to ensure continuity and effectiveness of patient care throughout 
  the healthcare continuum.
• Partner with physicians and their offices to ensure proper patient status and facilitate appropriate aftercare 
  upon discharge.
• Serve as a patient advocate, addressing and resolving care-related concerns to support patient satisfaction 
  and quality outcomes.

Utilization Management:

• Work in collaboration with the Utilization Management Committee, assisting with preparation for quarterly 
  Utilization Management Committee Meetings.
• Review medical records to evaluate the appropriateness of care and summarize findings for presentation to 
  the UM Committee.
• Communicate with insurance companies, Medicare, and other payors to ensure timely and appropriate 
  payment for services rendered.
• Monitor resource consumption and utilization to support cost-effective care without compromising quality.

Quality Standards and Performance Improvement:

• Ensure compliance with quality standards as determined by the Performance Improvement Plan and 
  Medical Staff Quality Indicators.
• Contribute to infection control surveillance and assist in data aggregation for quality trending and 
  reporting.
• Support institutional goals and objectives, serving as a resource to Senior Management and actively 
  participating in initiatives that enhance quality care.

Documentation and Reporting:

• Maintain thorough documentation for Utilization Management, including detailed records of interactions 
  with payors, patients, and interdisciplinary team members.
• Ensure accuracy and completeness of patient records in coordination with the business office, CFO, and 
  other stakeholders.
• Monitor and report on physician and hospital quality metrics, tracking the effectiveness of care and 
  utilization management practices.

Professional Development:

• Pursue ongoing professional growth opportunities and maintain required certifications, including RN 
  licensure and BLS.
• Participate in the Utilization Review Committee and relevant hospital training sessions.
• Stay current with industry practices and standards to continuously improve case management 
  effectiveness.
  

Education

• Graduate of an accredited school of Nursing, required

Licensure/Certification

• Current Texas RN License.
• Current Basic Life Support (BLS) certification accredited by American Heart Association (AHA) required.
• Certification in Case Management, preferred.

Specific Job Experience

• Previous experience in case management, with acute care experience