Utilization Management Nurse II
22 hours ago
Summary: The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse performs a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services "CMS" Inpatient List). They effectively manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and Joint Commission regulations and guidelines related to UM. This Nurse effectively communicates with internal and external clinical professionals, organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Management Nurse collaborates with other members of the health care team to ensure the above according to the mission of CHRISTUS. Responsibilities: Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders. Applies demonstrated clinical competency and judgment to perform comprehensive assessments of clinical information and treatment plans and apply medical necessity criteria to determine the appropriate level of care. Assess assigned patient population for medical necessity, level of care, and appropriateness of setting and services using MCG/InterQual Care Guidelines and/or health system-approved tools. Use appropriate criteria sets for admission reviews, continued stay reviews, outlier reviews, and clinical appropriateness recommendations. Coordinate and facilitate correct identification of patient status. Analyze documentation quality and collaborate with the physician and treatment team to obtain necessary documentation. Facilitate joint decision-making with the interdisciplinary team regarding changes in patient status and/or negative outcomes. Demonstrate and apply current knowledge of regulatory requirements for compliance. Utilize independent scope of practice to provide utilization review services and analyze information supplied by physicians to make timely review determinations. Take follow-up action when established criteria for service utilization are not met. Proactively refer cases to the physician advisor for medical necessity reviews. Effectively collaborate with the interdisciplinary team including the Physician Advisor for secondary reviews. Proactively review patients prior to admission to determine medical necessity and appropriate level of care. Review surgery schedules to ensure planned surgeries are ordered in the appropriate status and necessary authorizations are obtained. Regularly review patients in Observation status to determine appropriateness for discharge or conversion to inpatient status. Identify and resolve issues regarding clinical appropriateness recommendations and potential payor denials. Maintain consistent communication with payors to coordinate certification of hospital services. Coordinate patient care progression throughout the continuum and document to support medical necessity at each level of care. Evaluate care administered by the interdisciplinary health care team and advocate for standards of practice. Analyze assessment data to identify potential problems and formulate goals/outcomes. Follow CHRISTUS Guidelines related to HIPAA to prevent unauthorized disclosure of Protected Health Information (PHI). Attend scheduled department and interdepartmental meetings as appropriate. Demonstrate technology literacy and ability to work in multiple technology systems. Act as a catalyst for change in the organization; respond to change with flexibility and adaptability. Translate strategies into action steps; monitor progress and achieve results. Demonstrate competence to perform responsibilities in a manner that meets the population-specific and developmental needs of patients. Possess negotiating skills to interact with physicians, nursing staff, administrative staff, discharge planners, and payers. Excellent verbal and written communication skills, knowledge of clinical protocol, and health benefit plans. Adjust to frequently changing workloads and interruptions. May be asked to work overtime or take calls. May be asked to travel to other facilities to assist as needed. Actively participate in Multidisciplinary/Patient Care Progression Rounds. Escalate cases as appropriate per policy to Physician Advisors and/or CM Director. Document in the medical record per regulatory and department guidelines. Assist with special projects as needed. Serve as a preceptor or orienter to new associates. Assume responsibility for professional growth and development. Familiarity with criteria sets including InterQual and MCG preferred. Must have excellent verbal and written communication and ability to interact with diverse populations. Must have critical and analytical thinking skills. Must have demonstrated clinical competency. Must be able to multitask and function in a stressful, fast-paced environment. Must have knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement. Must understand pre-acute and post-acute levels of care and community resources. Must be able to work independently and exercise sound judgment in interactions with physicians, payors, patients, and families. Must understand internal and external resources and knowledge of available community resources. Other duties as assigned. Job Requirements: Education/Skills Graduate of an accredited School of Nursing OR demonstrated success in the Utilization Management Nurse I role for at least five years at CHRISTUS Health. Experience Two or more years of clinical experience with at least one year in the acute care setting OR demonstrated success as Utilization Management Nurse I role at CHRISTUS Health required. Licenses, Registrations, or Certifications RN License in state of employment or compact required. LPN or LVN license accepted for associates with 5 years of demonstrated success and experience in the Utilization Management Nurse I role at CHRISTUS Health. Certification in Case Management preferred. BLS preferred. Work Schedule: 7PM - 7AM Work Type: Full Time J-18808-Ljbffr
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Utilization Management Nurse II
4 days ago
Tyler, Texas, United States Christus Health Full timeJob SummaryWe are seeking a skilled Utilization Management Nurse II to join our team at Christus Health. This is a dynamic role that requires a strong understanding of clinical practices and the ability to analyze complex data.
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Tyler, Texas, United States Christus Health Full timeJob Overview">The Utilization Management Nurse II is a key role within CHRISTUS Health, playing a vital part in ensuring the optimal use of hospital resources while providing high-quality patient care. As a seasoned professional with strong clinical expertise, you will be responsible for conducting thorough reviews of patient cases to determine medical...
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Utilization Management Nurse II
3 weeks ago
Tyler, United States CHRISTUS Health Full timeDescriptionSummary: The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must...
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Utilization Management Nurse II
3 weeks ago
Tyler, United States Christus Health Full timeDescriptionSummary: The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must...
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Utilization Management Nurse II
2 months ago
Tyler, United States Christus Health Full timeDescriptionSummary: The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must...
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Tyler, Texas, United States Christus Health Full timeJob OverviewWe are seeking a highly skilled Utilization Management Nurse II to join our team at Christus Health. This is a full-time position, working 8AM - 5PM, Monday through Friday.ResponsibilitiesThe ideal candidate will have:Evaluate the clinical appropriateness of patient care and ensure efficient hospital resource utilization through comprehensive...
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Utilization Management Nurse II
3 weeks ago
Tyler, TX, United States Christus Health Full timeDescription Summary: The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must...
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Utilization Management Nurse II
3 weeks ago
Tyler, TX, United States Christus Health Full timeDescriptionSummary: The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must...
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Utilization Management Nurse II
2 days ago
Tyler, TX, United States Christus Health Full timeDescriptionSummary: The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must...
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Utilization Management Nurse Specialist
1 week ago
Tyler, Texas, United States Christus Health Full timeJob DescriptionWe are seeking a skilled Utilization Management Nurse Specialist to join our team at Christus Health.Responsibilities:Ensure medical necessity and proper hospital resource utilization of services.Perform pre-admission, concurrent, and retrospective UM related reviews and functions.Maintain current knowledge of commercial and government payors...
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Nurse Case Manager
1 week ago
Tyler, Texas, United States Christus Health Full timeAs a key member of our healthcare team, the Nurse Case Manager - Utilization Specialist plays a vital role in ensuring that patients receive the highest quality care while also promoting cost-effective and efficient use of hospital resources.Job DescriptionThe ideal candidate will possess strong clinical knowledge and analytical skills, with the ability to...
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Nursing Unit Manager
5 days ago
Tyler, Texas, United States Christus Health Full timeAbout Christus HealthChristus Health is a leading healthcare provider dedicated to delivering high-quality patient care and exceptional service. Our team of experienced professionals is committed to making a positive impact on the lives of our patients, families, and communities.Job DescriptionRole OverviewWe are seeking an accomplished Nursing Unit Manager...
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Clinical Resource Utilization Specialist
1 week ago
Tyler, Texas, United States Christus Health Full timeEstimated salary: $83,000 - $110,000 per yearAbout the RoleWe are seeking a highly skilled and experienced Clinical Resource Utilization Specialist to join our team at Christus Health. This is a full-time opportunity with a competitive salary range of $83,000 - $110,000 per year.Key ResponsibilitiesDetermine the clinical appropriateness of care provided to...
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Healthcare Utilization Specialist
5 days ago
Tyler, Texas, United States Christus Health Full timeJob DescriptionWe are seeking a highly skilled Healthcare Utilization Specialist to join our team at Christus Health. This is an exciting opportunity for a motivated and detail-oriented professional to make a meaningful impact in the healthcare industry.About the RoleThis position requires a strong clinical background, preferably with 2+ years of experience...
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Clinical Care Coordinator
5 days ago
Tyler, Texas, United States Christus Health Full timeJob Title: Clinical Care Coordinator - Utilization ManagementOverview:At Christus Health, we are committed to delivering exceptional patient care while promoting a culture of compassion, integrity, and excellence. As a Clinical Care Coordinator - Utilization Management, you will play a vital role in ensuring that our patients receive the right care at the...
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Clinical Resource Utilization Specialist
1 week ago
Tyler, Texas, United States Christus Health Full timeJob Summary:We are seeking a highly skilled Clinical Resource Utilization Specialist to join our team at Christus Health. As a key member of our clinical staff, you will play a critical role in ensuring the appropriate utilization of hospital resources and promoting high-quality patient care.About the Role:The Clinical Resource Utilization Specialist will be...
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Nurse Clinical Utilization Specialist
6 days ago
Tyler, Texas, United States Christus Health Full timeJob OverviewWe are seeking an experienced Nurse Clinical Utilization Specialist to join our team at Christus Health. In this role, you will be responsible for ensuring the clinical appropriateness of care provided to patients and optimizing hospital resource utilization.About the RoleThe ideal candidate will have a strong clinical background and excellent...
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Clinical Resource Manager
1 week ago
Tyler, Texas, United States CHRISTUS Health Full timeJob Overview:Innovative healthcare organization CHRISTUS Health seeks a skilled Clinical Resource Manager to lead utilization and care coordination efforts. This key role will drive optimal patient outcomes, enhance operational efficiency, and foster strategic partnerships within the healthcare ecosystem.Responsibilities:Evaluate clinical information,...
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Clinical Utilization Specialist
1 week ago
Tyler, Texas, United States Christus Health Full timeAbout the RoleWe are seeking a highly skilled Clinical Utilization Specialist to join our team at Christus Health. In this role, you will be responsible for optimizing hospital resource utilization and ensuring that patients receive the most appropriate level of care.Job SummaryThe Clinical Utilization Specialist will work closely with healthcare teams to...
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Administrative Assistant II Lead
1 week ago
Tyler, Texas, United States Towson University Full timeAbout the RoleWe are seeking an experienced Administrative Assistant II to join our team at Towson University. The successful candidate will be responsible for providing administrative support to the department, including budget management, travel coordination, and equipment inventory.
