Utilization Review RN_Health Plan

Company: Baylor, Scott & White Health
Location: Temple
Posted on: September 1, 2020

Job Description:

Job Description:

*UR RN Candidates should reside in one of the following markets - Austin, Temple or Lubbock - and will be able to work remotely / from home; in the future he/she will be expected to attend periodic meetings in Office* JOB SUMMARY The remote Utilization Review Registered Nurse (RN) provides a clinical review of cases using standard criteria to determine the medical appropriateness of inpatient and outpatient services, regardless of payor type. Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. Provides ongoing communication with health plan utilization departments regarding medical necessity for prospective, concurrent, and retrospective reviews. Intervenes when potential denials are determined and facilitates appeals when concurrent denials are received. Partners with physicians related to appropriateness of admission and the prevention of denials. ESSENTIAL FUNCTIONS OF THE ROLE Performs initial, concurrent, discharge and retrospective reviews of all cases, including: using medical guidelines to determine the medical appropriateness of inpatient and outpatient services; assessing, interpreting, and responding to the needs or requirements of patients; identifying, escalating and resoving complex cases or issues as required. Reviews current charts for appropriateness and correct admission status (inpatient, observation, bedded outpatients). Alerts and collaborates with appropriate Utilization Review leadership concerning patients who do not meet medical appropriateness criteria. Communicates with attending physician regarding patients who do not meet criteria in order to identify additional documentation needs or potential status change. Coordinates care and discharge planning. Makes arrangements for appropriate post-hospital care, incuding physical and behavioral medicine, transportation, equipment, home health care, etc. Communicates problems or trends to the appropriate leadership within the Health Plan. Identifies, documents and communicates potential quality assurance or risk management issues as appropriate. Participates in process improvement projects, including the evaluation, development and implementation of protocols, policies and procedures to continuously enrich care coordination efforts and ensure evidenced-based processes are utilized. Perform service recovery efforts to support provider and member satisfaction. KEY SUCCESS FACTORS Advanced understanding of general health care modalities, therapies, terminology and equipment. Ability to understand the customer's point of view and take ownership of creating a solution to their issues. Knowledge and use of discharge planning, case management, utilization review and levels of care. Knowledge of applicable federal and state regulatory requirements, including TDI, CMS, DOL, HHSC and NCQA standards and requirements. Must be able to communicate thoughts clearly; both verbally and in writing. Interpersonal skills to interact with a wide-range of constituencies. Must have critical thinking and problem-solving skills. Ability to balance multiple demands and respond to time constraints. Ability to analyze, understand and act on detailed clinical care documentation. General computer skills, including but not limited to: Microsoft Office, information security, scheduling and payroll systems, electronic medical documentation, and email. Certified Case Manager (CCM) or Accredited Case Manager (ACM) preferred. BENEFITS Our competitive benefits package includes the following - Immediate eligibility for health and welfare benefits - 401(k) savings plan with dollar-for-dollar match up to 5% - Tuition Reimbursement - PTO accrual beginning Day 1 Note: Benefits may vary based upon position type and/or level QUALIFICATIONS - EDUCATION - Associate's degree at minimum required - EXPERIENCE - 3 Years of Experience - CERTIFICATION/LICENSE/REGISTRATION - Registered Nurse (RN)

Keywords: Baylor, Scott & White Health, Temple , Utilization Review RN_Health Plan, Other , Temple, Texas