The Utilization Review Nurse works independently to plan, implement, and/or coordinate quality patient care and cost effective utilization of healthcare services. Utilization Review Nurse coordinates medical and/or pharmacy prior authorization request, perform preadmission, concurrent and retrospective review of inpatient admissions and outpatient services, identifies cases for case management.
· Applies nationally accepted criteria that include general rules and time definitions to determine appropriate levels of care and to illuminate resource utilization practices with provider organizations.
· Skill and proficiency in applying highly technical and critical thinking principles, concepts, and techniques that are central to the Nursing profession.
· Provides telephonic case management, referral of resources, education and other clinically based activities to plan member.
· Provides medical management to plan members through communications with the members, the physician, other health care providers, the employer and the referral source.
· Makes recommendations regarding health resources.
· Collect clinical data and enters information into database for documentation purposes.
· Monitors and evaluates the member's response to health care needs.
· Evaluates member's treatment plan for appropriateness, medical necessity and cost effectiveness.
· Implements care such as negotiating the delivery of durable medical equipment, assist with discharge planning, when applicable, and assist with arranging equipment through \t designated vendors.
· Maintains an active caseload providing interventions as needed within area of expertise and limits of credentials.
· Acquires and provides detailed information regarding an assigned member to establish the foundation for treatment plan.
· Works with member using professional judgment and discretion to implement the team determined Team Plan.
· Maintains a high level of ethical conduct regarding confidentiality, dual-relationships, and professional stature.
· Participate in continuing education activities, remaining knowledgeable in areas of expertise
· Attend meetings as appropriate and meet regularly with supervisor to exchange pertinent information and receive supervision
· Timely completion of documentation, follow-up, etc. within specified deadlines.
· Perform verification and pre-certification authorizations using approved guidelines, screening criteria and protocols and refers authorizations to the Medical Director that require additional expertise.
· Perform concurrent review to validate the medical necessity for admissions, determine the appropriate level of care and the necessity for continued inpatient stay.
· Monitor retrospective review requests based on established review guidelines.
· Assist with discharge planning for members who have been hospitalized.
· Provide appropriate consultation and referral to Case Management Personnel.
· Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources.
· Conduct patient satisfaction surveys.
· Other duties as designed by Management.
· MUST maintain a current RN or LVN license in the State of Texas
· MUST HAVE prior experience with Utilization Management
· MUST have prior experience with a physician network or health plan
· MUST have Milliman Guidelines (MCG) experience
· MUST have flexibility to adjust the schedule occasionally in order to accommodate other schedules and/or deadlines or projects
· Preferred knowledge in case management principles, utilization management procedures and practices
In a full-time permanent position, you will be able to participate in our company benefit program which includes:
· Group benefits include medical, dental, vision, company paid $25k life with the option to add more voluntary life insurance coverage for employee and their family, STD, company paid LTD, 401k, and a variety of supplemental coverages such as hospital, cancer, legal, etc. available to the employee and their family.
· Employer funded HSA and HRA programs.
· Paid Time Off ranging from 5-28 days depending on length of service.
· Profit Sharing Bonus Program
· 100% Employer Paid Pension Plan after 5 years
· Access to company gym and locker rooms in Houston offices.
Job Type: Full-time