Health Plan Utilization Management RN
Company: Baylor Scott White Health
Posted on: September 14, 2018
Health Plan Utilization Management RN
The UM Nurse performs utilization management, utilization review, and/or concurrent review for the Scott & White Health Plan's (SWHP) Leading Change Care Coordination Team. The UM Nurse reviews cases using standard, specific guidelines and algorithms to process assigned events. The UM Nurse determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines. The UM Nurse manages the utilization functions within the following areas: Contracted (nuclides DRG), DME and HH, and outpatient approvals and denials.
The UM Nurse performs functions related to standard cases for utilization management, utilization review, and/or concurrent review, including: (1) assessing, interpreting, and responding to customer needs or requirements; (2) identifying solutions to non-standard requests and problems; (3) transforming concepts into practice keeping the member at the center of decision making, and (4) determining medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines (InterQual, SWHP Medical Policy, CMS criteria, etc.) and benefit determination. The UM Nurse completes comprehensive documentation as outlined in policies, standard operating procedures, job aids, and workflows. The UM Nurse identifies, documents and communicates potential quality assurance/ risk management issues to the appropriate entity/department manager, directors, AVP and/or the QI committee as instructed ensuring member/provider needs are met. The UM Nurse participates in process improvement projects to continuously enrich care coordination efforts and ensure evidenced based processes are utilized. The UM Nurse clearly communicates Population Management policy decisions and changes to other departments and Divisions. The UM Nurse acts as a consultant to staff and Plan members in responding appropriately to inquiries and providing clarification on Population Management policies
The ideal candidate for the UM Nurse role will have broad medical-surgical experience. The ideal candidate for the UM Nurse role will maintain current knowledge on available resources within the system and readily shares that information with other health care professionals, staff members, SWHP/ICSW members and their families. The ideal candidate for the UM Nurse role will also be able to understand and implement TDI, CMS, DOL, HHSC and NCQA standards and requirements.
Location/Facility - Health Plan
For more information on the facility, please click our Locations link.
Specialty/Department/Practice - Nursing
Shift/Schedule - Full Time Days
Benefits - Our competitive benefits package includes*:
Immediate eligibility for health and welfare benefits
401(k) savings plan with dollar-for-dollar match up to 5%
PTO accrual beginning Day 1
*Note: Benefits may vary based upon position type and/or level.
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation's exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it's accepting a calling!
H.S. Diploma/GED Equivalent
3+ Years Experience
RN or LVN License
S&W Health Plan - West Campus (11042)
1206 W Campus Dr
Keywords: Baylor Scott White Health, Temple , Health Plan Utilization Management RN, Healthcare , Temple, Texas
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