PRN Utilization Review RN - M-F Days

JOB SUMMARY
Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations and documentation requirements.

ESSENTIAL FUNCTIONS

Job Duties

• Collaborates with the Central Scheduling Department (CSD) team to provide accurate and complete clinical information in order to obtain authorization.
• Conducts admission reviews for Medicare and Medicaid beneficiaries as well as private insurance members and self-pay patients utilizing evidence-based guidelines.
• New admission reviews are done concurrently at the point of entry when the admission order is placed and necessary clinical information is available in the medical record.
• Communicate with admitting physicians and physician advisors when documentation does not appear to support hospital level of care.
• Use hospital approved medical necessity tool to determine level of care for inpatient or observation/outpatient services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two-midnight stay.
• Keeps current on all Federal, State and local regulatory changes that affect delivery or reimbursement of acute care services within the scope of Utilization Management. Uses knowledge of national and local coverage determinations to appropriately advise physicians.
• Proactively collaborates with admitting physician to provide accurate level of care determination at the time of review.
• Escalates identified progression-of-care/patient flow barriers to appropriate departments.
• Actively participates in daily huddles, departmental meetingsand education offerings.
• Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes.
• Educates members of the patient's care team on the appropriate access to and use of various levels of care.
• Promotes use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care.
• Serves as a resource person to physicians, care coordinators, physician offices and billing office for coverage and compliance issues.
• Completes all reviews within department established policies and best practice standards. Meets department quality standards as established for the department, ie: Inter-rater Reliability audits, completing all initial reviews within established time frames, completes concurrent and discharge reviews to meet department and industry standards.
• Performs other duties as assigned.

QUALIFICATIONS

Education and Experience

Required

• Education
  Graduate of accredited nursing program and holds an active unrestricted RN license in the State of Texas.

• Experience
  5 years experience to include 2 years of clinical experience and minimum of 3 years of recent utilization review experience.
  Prior experience with Epic CCM.

• Licenses and Certifications
  (RN) REGISTERED NURSE holds an active unrestricted RN license in the State of Texas.

Preferred

• Experience
  Acute care experience preferred.

Knowledge, Skills and Abilities

• Actively participates in the department's performance improvement initiatives.
• Basic computer skills and knowledge.
• Expert knowledge of hospital approved, evidence based medical necessity tool and knowledge of local and national coverage determinations.
• Identifies avoidable days (quality and risk issues), makes appropriate referrals. Confers with Manager and/or Medical Director as appropriate.
• Identifies the need for professional growth and seeks out appropriate development opportunities.
• Evaluates outcomes data to identify trends and areas for improvement (i.e. avoidable days, denial information).
• General good health and stress coping ability.
• Ability to speak and hear, to allow discussions with physicians, patients, and other members of the healthcare team.
• Possess near vision acuity for accurate reading of computer screens and recording on patient charts.

PHYSICAL DEMANDS/WORKING CONDITIONS

• Physical Demands
  Talking

• Working Conditions
  Office Setting

Security

This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information.

EEO Statement

UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.

UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include:
• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100% coverage for preventive healthcare - no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer
• Learn more about these and other UTSW employee benefits!