Registered Nurse Utilization Review - PRN - M-F Days

Registered Nurse Utilization Review

PRN Remote

Why UT Southwestern?

With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the #1 hospital in Dallas-Fort Worth for the sixth consecutive year, we invite you to continue your healthcare career with us at William P. Clements Jr. University Hospital. You’ll discover a culture of teamwork, professionalism, and consistent opportunities for learning and advancement into leadership roles.

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.

Conducts inpatient admission review for Medicare and Medicaid beneficiaries as well as private insurance members and self-pay patients based on evidence-based guidelines. Confers with admitting physicians when documentation does not appear to support hospital level of care and offers suggestions for clarity and completeness. Uses InterQual Level of Care Criteria for appropriateness for inpatient level of care or observation services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two-midnight stay.

Experience and Education

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

·       Minimum of 5 years of experience to include 2 years of clinical experience and minimum of 3 years of recent Utilization Review experience.

·       Current experience with utilizing a medical necessity tool to perform utilization reviews.            

·       Acute Care experience is preferred.           

·       Basic computer skills and knowledge.

·       Prior experience with Epic CCM                                                                                                                                                

Knowledge, Skills and Abilities                                                            

·       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. 

·       Identifies avoidable days (quality and risk issues), makes appropriate referrals.  Confers with Manager and/or Medical Director as appropriate.

·       Actively participates in the department’s performance improvement initiatives.

·       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)   

Job Duties

·       Collaborates with the access management team to provide accurate and complete clinical information in order to obtain authorization.                                                          

·       Conducts inpatient admission review for Medicare and Medicaid beneficiaries as well as private insurance members and self-pay patients based on evidence-based guidelines.                                                 

·       Admission reviews are done concurrently at the point of entry in collaboration with ED and admitting physician and the cooperation with the access management team to determine the appropriateness of hospital level of care.        

·       Confers with admitting physicians when documentation does not appear to support hospital level of care and offers suggestions for clarity and completeness.                                                    

·       Uses InterQual Level of Care Criteria for appropriateness for inpatient level of care or observation 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 coaching on accurate level of care determination at point-of-hospital entry.                                                      

·       Consistently identifies and records information on any progression-of-care/patient flow barriers.

·       Actively participates in daily huddles, multidisciplinary rounds and patient care conferences to maintain knowledge about intensity of services and the progression of care.

·       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.

·       Works closely with decision support staff to review resource utilization data and trends to identify outliers who may benefit from real-time coaching to improve outcomes.

·       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.

Working Conditions

This job is remote only and individuals who reside in the job will permanently work 100% from an alternate approved worksite.

Any qualifications to be considered as equivalents in lieu of stated minimums require prior approval of the Vice President for Human Resources Administration, or his/her designee.

To learn more about the benefits UT Southwestern offers, visit https://www.utsouthwestern.edu/employees/hr-resources/

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

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.