Utilization Review Nurse
2 months ago
POSITION SUMMARY: The Utilization Review Nurse ensures the delivery of cost-effective quality care within an appropriate length of stay.JOB SPECIFIC RESPONSIBILITIES:General Responsibilities:•Maintains PHI and HIPAA for each patient in accordance with hospital policy and federal regulations.•Promotes safety in the workplace and a safe patient environment at all times•Practices "minimum information necessary" when performing UR, case management, and discharge functions•Acts as a patient advocate for all facility patients•Adheres to all company and professional ethical, legal, and accreditation/regulatory standards•Respects and promotes individual patient privacy and confidentiality•Demonstrates knowledge and support of the organization's mission, vision, values, and strategic initiatives.•Demonstrates understanding of and upholds the organization's Quality, Risk, and Continuum of Care programphilosophy.UTILIZATION REVIEW MANAGEMENT (UM) RESPONSIBILITIES (75% of time performing duty)•For all hospital admissions, this position will review medical necessity within two business days of admission andwill be based on medical record documentation on the chart within 48 hours of admission and document usingthe appropriate UR form. Assist with Pre-admission referral reviews and concurrent and discharge criteriareviews, as needed.•Completes ongoing concurrent and discharge UM reviews at least every seven days or as required by the payor.All UM reviews will be documented per policy. Follows the UM process for referral of cases to PhysicianAdvisor/Medical Director when appropriate.•Participates in weekly UM meetings to review all outstanding cases for appropriateness of admission anddischarge and the need for continued stay. Identifies potential barriers and obtains appropriate physicianintervention when necessary.•Completed all UM reviews within stated time frames and follows UM process for additional clinical reviews whennecessary.•Provides clinical updates to third-party payors after admission within stated time frames to obtain continued stayauthorization. All interactions and results of interactions with third-party payors are documented in the•MEDITECH system. This documentation includes the level of care, number of days approved, and next review due date.•Provides utilization management equally to all patients regardless of payor source.•Maintains documentation in the chart in a timely fashion and communicates any changes timely to third-partypayors to update authorization of ongoing medical care appropriate to patient needs.•Follows clinical review process to assist in the appropriate management of patient medical services and facilitatedischarge to the appropriate level of care in a timely and cost-effective manner.•Identifies/tracks/trends/analyzes selected variations (variance=patient/family, practitioner, system, orcommunity) which affect patient care, resource management or length of stay. Completes statistical and otherreports as required in a timely manner.•Ensures utilization of medical resources for patients efficiently and effectively•Maintains a safe environment•Participates in Quality Improvement, UM Committee, and Risk Management as indicated•Attends department meetings and mandatory in-services. Performs other duties as assigned.POSITION QUALIFICATIONS:EDUCATION:•Minimum Bachelor's degree in a Health care field.•Bachelor's degree in nursing (BSN) desired.EXPERIENCE:•Two (2)-three (3) years of experience in hospital case management, utilization management, or dischargeplanning of complex medical/surgical cases•Proficient in evaluating complex clinical documentation•Strong analytical and organizational skills•Working knowledge and ability to apply professional standards of practice in the work environment.•Knowledge of specific regulatory, managed care, and accreditation requirements•Computer proficiencyLICENSURE/CERTIFICATION:•Must maintain current licensure in good standing during employment, as applicable.•Must obtain CEUs in accordance with state requirements for licensure.
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Registered Nurse
1 month ago
Houston, United States St. Joseph's Medical Center Full timePOSITION SUMMARY: The Utilization Review Specialist is responsible for assisting in the facilitation of critical criteria reviews on patients for behavioral medicine admissions and continued stays, completion of certifications/interfaces with managed care organizations, external reviewers and other payers. JOB DETAILS: Full time day shift PRINCIPAL DUTIES...
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Clinical Utilization Review Specialist
1 month ago
Houston, Texas, United States St. Joseph's Medical Center Full timeJob Summary:The Utilization Review Specialist is a key member of our healthcare team, responsible for ensuring the medical necessity of patient admissions and continued stays. This role requires a strong clinical background, excellent communication skills, and the ability to work collaboratively with physicians and other healthcare professionals.Key...
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Utilization Review Nurse
4 weeks ago
Houston, United States Elite Full timeUtilization Review Nurse for Workers' Comp Job Purpose: Review Workers Compensation requests submitted by the provider, requestor, claimant or carrier to determine the medical necessity of the treatment utilizing clinical expertise and evidence-based treatment guidelines. Duties: Perform an evaluation of the medical data for utilization review...
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Clinical Review Nurse
2 weeks ago
Houston, TX, United States Centene Full timeYou could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. ****NOTE: This is a fully remote role. Preference will be given to applicants...
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Clinical Review Nurse
2 weeks ago
Houston, United States Spectraforce Technologies Full timeTitle: Clinical Review Nurse - Prior Authorization Duration: 03 Months (Contract to Hire) Location: Remote - Nationally Sourced Shift: Monday - Friday. (Can be EST (highly preferred), CST (second preference). (We can negotiate schedules. If someone is willing to work weekends that would be in the future. On the weekends we have a skeleton crew and generally...
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Houston, United States Axelon Full timeLocation: Remote - sourced nationally. SHIFT: Monday - Friday (8 hours) In the beginning they will not have a set weekend commitment. Once the new hire is fully trained, they are going to have to work (8) hours per day Monday - Friday. (Can be EST (highly preferred), CST (second preference). ( Client will negotiate schedules. If someone is willing to work...
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Houston, United States Axelon Services Corporation Full timeLocation: Remote sourced nationally. SHIFT: Monday Friday (8 hours) In the beginning they will not have a set weekend commitment. Once the new hire is fully trained, they are going to have to work (8) hours per day Monday Friday. (Can be EST (highly preferred), CST (second preference). (Client will negotiate schedules. If someone is...
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RN Clinical Reviewer
4 weeks ago
Houston, United States HCA Full timeDescription Introduction Are you looking for a work environment where diversity and inclusion thrive? Submit your application for our RN Clinical Reviewer opening with HCA Houston Healthcare Northwest today and find out what it truly means to be a part of the HCA Healthcare team. Benefits HCA Houston Healthcare Northwest, offers a total rewards package...
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Utilities Engineer
3 months ago
Houston, United States System One Full timeSystem One is seeking a Utilities Engineer for a direct hire role in Houston Tx. The Utilities Engineer will monitor condition, ensure optimal & efficient performance, guide investment priority, lead change, implement enhancements and be responsible for the overall operational excellence of all plant related utilities for Monument Chemical. The Utilities...
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RN Clinical Reviewer
2 months ago
Houston, United States HCA Houston Healthcare Northwest Full timeDescription IntroductionAre you looking for a work environment where diversity and inclusion thrive? Submit your application for our RN Clinical Reviewer opening with HCA Houston Healthcare Northwest today and find out what it truly means to be a part of the HCA Healthcare team.BenefitsHCA Houston Healthcare Northwest, offers a total rewards package that...
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RN Clinical Reviewer
2 months ago
Houston, United States HCA Houston Healthcare Northwest Full timeDescription IntroductionAre you looking for a work environment where diversity and inclusion thrive? Submit your application for our RN Clinical Reviewer opening with HCA Houston Healthcare Northwest today and find out what it truly means to be a part of the HCA Healthcare team.BenefitsHCA Houston Healthcare Northwest, offers a total rewards package that...
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Project Manager
6 months ago
Houston, United States BGE, Inc. Full timeBGE, Inc. is a nationwide engineering consulting firm that provides services in civil engineering, planning, landscape architecture, construction management, survey and environmental services for public and private clients. Our employees enjoy a comprehensive benefits package to include outstanding health care, generous 401(k) match, career mapping and...
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Project Manager
2 months ago
Houston, United States BGE Full timeBGE, Inc. is a nationwide engineering consulting firm that provides services in civil engineering, planning, landscape architecture, construction management, survey and environmental services for public and private clients. Our employees enjoy a comprehensive benefits package to include outstanding health care, generous 401(k) match, career mapping and...
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Managed Review Project Manager
3 weeks ago
Houston, United States TransPerfect Full timeWho We Are:TransPerfect is the world's largest provider of language services and technology solutions for global business. From offices in over 100 cities on six continents, TransPerfect offers a full range of services in 170+ languages to clients worldwide. More than 5,000 global organizations employ TransPerfect's GlobalLink® technology to simplify...
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Houston, Texas, United States CVS Health Full timeAt CVS Health, we're committed to delivering innovative solutions that make healthcare more personal, convenient and affordable.Position OverviewWe're seeking a skilled Behavioral Health Clinical Utilization Specialist to join our team. As a key member of our clinical team, you'll play a critical role in assessing the appropriateness of treatment plans and...
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Utilization Management Asst, Team Lead
2 weeks ago
Houston, United States Texas Children's Hospital Full timeJob Description We're looking for a Utilization Management Assistant, Team Lead, someone who's ready to grow with our company. In this position you will provide leadership support and oversight of daily inventory of cases/authorizations and UM processes to ensure compliance. Provide assistance or information regarding member and provider needs regarding...
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Houston, United States Texas Children's Hospital Full timeJob Description We're looking for a Utilization Management Physical a Therapy Specialist, someone who's ready to grow with our company. In this position you will provide prior authorization of outpatient and home physical and occupational therapy services requiring authorization. This process includes using clinical judgement for utilization management,...
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Nurse Specialist
1 month ago
Houston, Texas, United States St. Joseph's Medical Center Full timeJob Summary:The Utilization Review Specialist at St. Joseph Medical Center is responsible for ensuring the medical necessity of patient admissions and continued stays. This role involves reviewing patient medical records, evaluating the appropriateness of care, and completing required forms.Key Responsibilities:Reviews patient medical records to collect data...
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Utilization Management PT/OT Therapy Specialist
2 weeks ago
Houston, United States Texas Children's Hospital Full timeJob Description We're looking for a Utilization Management Physical a Therapy Specialist, someone who's ready to grow with our company. In this position you will provide prior authorization of outpatient and home physical and occupational therapy services requiring authorization. This process includes using clinical judgement for utilization management,...
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Outpatient Nurse
2 weeks ago
Houston, United States SUN Behavioral Houston Full timeOutpatient Nurse (RN)Position Summary: Provides nursing care through physical and mental assessments, plans of care and therapeutic treatments of Partial Hospitalization Patients. Knowledgeable of a wide range of disorders; cognitive, emotional, developmental, social and behavioral. Performs crisis intervention. Participates in the department's performance...
