Registered Nurse Utilization Review
This position is responsible for analyzing clinical information submitted by medical providers to evaluate the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Is responsible for clinical review of all requested services for appropriateness based on clinical criteria. Performs selected member calls to address post hospital discharge services, ongoing durable medical equipment usage and other telephonic follow up identified by UM/CM Management. This position will facilitate with negotiations for out of network care.
- Proactively analyze information submitted by providers to make timely medical necessity review determinations based on appropriate criteria and standards and within governmental and contractual guidelines
- Identify and present cases of possible quality deviation, questionable admissions and prolonged length of stay to the Medical Director for further determination
- Collects accurate data for the system input by using correct coding of diagnosis and/or procedures.
- Processes authorization requests via phone queue according to internal departmental processes
- Performs selected member calls to address post hospital discharge services, ongoing durable medical equipment usage, and other telephonic follow up identified by UM/CM Management.
- Establishes and maintains rapport with providers as well as ongoing education of providers concerning appropriate protocol
- Collaborates and maintain open communications with all other departments as appropriate and required to facilitate completion of tasks/goals.
- Facilitate negotiations for out of network care
- Collaborate with all other departments as appropriate and required to facilitate the completion of tasks/goals
- Maintain quality documentation of collected data, actions take, and results of actions taken in order to promote continuity of care within governmental and contractual requirements
- Self-starter with ability to handle multiple projects at one time
- Demonstrates organizational, time management, prioritization and team work skills
- Follows the CHRISTUS Guidelines related the Health Insurance Portability and Accountability ACT ( HIPPA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
- Communication, Collaboration, and Coordination with customers, internal and external
- Present and/or facilitate one departmental in-service per calendar year
- Attend monthly departmental staff meetings and/or interdepartmental meetings as appropriate
- Analytic ability to prepare status reports and document procedures
- Excellent communications skills, judgment, initiative, critical thinking and problem solving abilities
- Ability to handle and resolve complex issues
- Ability to work occasional long or irregular hours
- Ability to work a flexible work schedule.
- Graduate of an accredited Registered Nursing Program, Bachelor Degree preferred
- Basic Knowledge of computer systems
- Good typing skills
- Excellent customer service skills
- Excellent negotiation skills
- Minimum of three years diverse clinical experience as RN
- Minimum of two years case management and/or utilization review experience
- Current/Active Texas RN Licensure
About the Company
In 1999, two historic Catholic charities became one, forming CHRISTUS Health and creating a unique purpose in the modern health care market - to take better care of people.
To extend the healing ministry of Jesus Christ, the mission that the Sisters of Charity Health Care system and Incarnate Word Health system shared for more than a century, is now also the mission of CHRISTUS Health.
Ranked among the top 10 Catholic health systems in the United States by size, the CHRISTUS Health system includes more than 40 hospitals and facilities in seven U.S. states, Chile and six states in Mexico, with assets of more than $4.6 billion.
Whether seeking care in Alexandria Louisiana, or Coahuila, Mexico, patients discover that the healing spirit is alive at CHRISTUS Health.