The Utilization Review Nurse is a registered nurse who provides clinical review against standard criteria for evaluating medical necessity for hospitalization, regardless of payor type. The Utilization Review Nurse 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. The Utilization Review Nurse provides ongoing communication with health plan utilization departments regarding medical necessity for prospective, concurrent, and retrospective reviews. The Utilization Review Nurse intervenes when potential denials are determined and facilitates appeals when concurrent denials are received and partners with physicians related to appropriateness of admission and the prevention of denials.
WHAT IS EXPECTED (ESSENTIAL FUNCTIONS)
1. Perform initial, concurrent, discharge and retrospective reviews on all patients.
2. Review current charts for appropriateness and correct admission status (inpatient, observation, bedded outpatients).Communicate directly with insurance companies and/or payor to obtain admission and continued stay certification or recertification
3. Facilitate peer to peer appeal for concurrent denials
4. Fax reviews per policy and as needed to stay current on certified days.
5. Collaborate with Care Coordination Medical Director on patients not meeting criteria and informs Clinical Resource Manager/Director as needed.
6. Assign a working diagnosis related groups (DRGs) on all patients.
7. Communicate with attending physician regarding patients who do not meet criteria to identify additional documentation needs or potential status change.
8. Communicate identified patients who do not meet criteria to Care Coordination for discharge planning
9. Communicate problems or trends with insurance companies to Clinical Resource Manager/Director
10. Perform chart analysis on quality surveillance and special studies as requested
The ideal candidate has the ability to analyze documentation of clinical care; has excellent written and verbal communication skills; is a critical thinker and has excellent time management skills.
* Location/Facility – Dallas, TX
For more information on the facility, please click our Locations link.
* Specialty/Department/Practice – Utilization Review
* Shift/Schedule – Weekends
* 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%
* Tuition Reimbursement
* 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!