Utilization Review RN

3 days ago

Dallas, United States Baylor Scott & White Health Full time

About Us At Baylor Scott & White Health, we support the health of people, families, and communities. Baylor Scott and White is Texas's largest not-for-profit healthcare system, encouraging healthy living. Our Core Values are: * We serve faithfully by doing what's right with a joyful heart. * We never settle by constantly striving for better. * We are in it together by supporting one another and those we serve. * We make an impact by taking initiative and delivering exceptional experience. Benefits Our competitive benefits package empowers you to live well and provides: * Eligibility on day 1 for all benefits * Dollar-for-dollar 401(k) match, up to 5% * Debt-free tuition assistance, offering access to many no-cost and low-cost degrees, certificates and more * Immediate access to time off benefits At Baylor Scott & White Health, your well-being is our top priority. Note: Benefits may vary based on position type and/or level Job Summary You will review patient cases for medical necessity and help establish inpatient and outpatient service suitability. You'll educate healthcare team on resource use to ensure timely care plan follow-through. Your job includes staying in contact with the patient's health plan and provider's care coordination departments. Your expertise is needed for reviewing medical necessity. Working with the team, you'll verify medical records reflect services provided, ensuring quality care and efficient resource use. What You'll Do * You will review medical services. Use guidelines to assess appropriateness. * Evaluate patient needs and requirements. * Your duties will include reviewing medical records to confirm that the content supports an appropriate level of care. * Should you encounter cases not meeting medical appropriateness criteria, you'll alert relevant teams and coordinate actions during denials. * As part of your role, you'll also streamline the authorization process and anticipate discharge requirements. * Clear communication of issues or trends impacting specific entities to the appropriate management is expected. * Part of your work will involve identifying and conveying potential quality assurance or risk management issues. * To improve patient care, join projects to enhance care coordination and implement evidence-based procedures for best standards. * In order to enhance the relationship with providers and members, you'll also perform service recovery tasks. What Will Make You Successful In The Role * An advanced understanding of healthcare procedures, treatments, terms, conditions, and equipment. * An ability to see the world from our customers' eyes and find resolutions to fit their needs. * Proficiency in discharge planning, setting case management referral standards, reviewing utilization, and categorizing levels of care. * Excellent communication skills with a knack for expressing your thoughts clearly, whether orally or in writing. * Effective interpersonal abilities to interact positively and cooperatively with a variety of people. * Exceptional critical thinking and problem-solving skills for dealing with complex situations. * The ability to juggle multiple tasks and responsibilities while sticking to deadlines. * Proficiency in scrutinizing, understanding, and applying detailed clinical care documentation. * Computer literacy, especially in Microsoft Office and medical documentation systems. * Case management certifications, such as Certified Case Manager, are beneficial but not necessary for this position. Belonging Statement We believe everyone should feel welcomed, valued, and supported. Our workforce should reflect our communities. Qualifications * Completion of an Associates degree in Nursing is necessary. * At least three years of professional experience is required. * You must hold a valid Registered Nurse License.

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