Utilization Management Nurse II

2 months ago


Tyler, United States Christus Health Full time
Description

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 competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services "CMS" Inpatient List). They effectively and efficiently 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, efficiently 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 as necessary 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 in order to perform comprehensive assessments of clinical information and treatment plans and apply medical necessity criteria in order to determine the appropriate level of care.
  • Resource/Utilization Management appropriateness: Assess assigned patient population for medical necessity, level of care, and appropriateness of setting and services. Utilizes MCG/InterQual Care Guidelines and/or health system-approved tools to track impact and variance.
  • Uses appropriate criteria sets for admission reviews, continued stay reviews, outlier reviews, and clinical appropriateness recommendations.
  • Coordinate and facilitate correct identification of patient status.
  • Analyze the quality and comprehensiveness of documentation and collaborate with the physician and treatment team to obtain documentation needed to support the level of care.
  • Facilitates joint decision-making with the interdisciplinary team regarding any changes in the patient status and/or negative outcomes in patient responses.
  • Demonstrates, maintains, and applies current knowledge of regulatory requirements relative to the work process in order to ensure compliance, i. e. IMM, Code 44.
  • Demonstrate adherence to the CORE values of CHRISTUS.
  • Utilize independent scope of practice to identify, evaluate and provide utilization review services for patients and analyze information supplied by physicians (or other clinical staff) to make timely review determinations, based on appropriate criteria and standards.
  • Take appropriate follow-up action when established criteria for utilization of services are not met.
  • Proactively refer cases to the physician advisor for medical necessity reviews, peer-to-peer reviews, and denial avoidance.
  • Effectively collaborate with the Interdisciplinary team including the Physician Advisor for secondary reviews.
  • Proactively review patients at the point of entry, prior to admission, to determine the medical necessity of a requested hospitalization and the appropriate level of care or placement for the patient.
  • Review surgery schedule to ensure planned surgeries are ordered in the appropriate status and that necessary authorization has been obtained as required by the payor or regulatory guidance (i. e., CMS Inpatient Only List, Payor Prior Authorization matrix, etc.)
  • Regularly review patients who are in the hospital in Observation status to determine if the patient is appropriate for discharge or if conversion to inpatient status is appropriate.
  • Proactively identify and resolve issues regarding clinical appropriateness recommendations, coverage, and potential or actual payor denials.
  • Maintain consistent communication and exchange of information with payors as per payor or regulatory requirements to coordinate certification of hospital services.
  • Coordinate and facilitate patient care progression throughout the continuum and communicate 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.
  • Follows the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability ACT (HIPPA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
  • Attend scheduled department staff meetings and/or interdepartmental meetings as appropriate.
  • Possesses and demonstrates technology literacy and the ability to work in multiple technology systems.
  • Act as a catalyst for change in the organization; respond to change with flexibility and adaptability; demonstrate the ability to work together for change.
  • Translate strategies into action steps; monitor progress and achieve results.
  • Demonstrate the confidence, drive, and ability to face and overcome challenges and obstacles to achieve organizational goals.
  • Demonstrate competence to perform assigned responsibilities in a manner that meets the population-specific and developmental needs of patients served by the department.
  • Possess negotiating skills that support the ability to interact with physicians, nursing staff, administrative staff, discharge planners, and payers.
  • Excellent verbal and written communication skills, knowledge of clinical protocol, normative data, and health benefit plans, particularly coverage and limitation clauses.
  • Must adjust to frequently changing workloads and frequent interruptions.
  • May be asked to work overtime or take calls.
  • May be asked to travel to other facilities to assist as needed.
  • Actively participates in Multidisciplinary/Patient Care Progression Rounds.
  • Escalates cases as appropriate and per policy to Physician Advisors and/or CM Director.
  • Documents in the medical record per regulatory and department guidelines.
  • May be asked to assist with special projects.
  • May serve as a preceptor or orienter to new associates.
  • Assumes 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 have the ability to Multitask and to function in a stressful and fast-paced environment.
  • Must have working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
  • Must have an understanding of pre-acute and post-acute levels of care and community resources.
  • Must have the ability to work independently and exercise sound judgment in interactions with physicians, payors, patients, and their families.
  • Must have an understanding of 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 on top of required experience in lieu of education required.

  • 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:

8AM - 5PM Monday-Friday

Work Type:

Full Time


EEO is the law - click below for more information:

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact us at .



  • Tyler, Texas, United States Christus Health Full time

    Job 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.


  • Tyler, United States 340B Health Full time

    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...


  • Tyler, Texas, United States Christus Health Full time

    About the RoleWe are seeking a highly skilled Utilization Management Nurse II to join our team at Christus Health. As a key member of our healthcare optimization team, you will play a critical role in ensuring that patients receive the most appropriate level of care while minimizing unnecessary costs.


  • Tyler, Texas, United States Christus Health Full time

    Job 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...


  • Tyler, United States CHRISTUS Health Full time

    DescriptionSummary: 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...


  • Tyler, Texas, United States Christus Health Full time

    Job Overview">This is a dynamic role at Christus Health, where you will utilize your clinical expertise to optimize healthcare outcomes for patients. As a Utilization Management Nurse II, you will be responsible for ensuring the medical necessity of hospital stays and services.">About the Job">We are seeking a skilled and dedicated nurse to join our team....


  • Tyler, United States Christus Health Full time

    DescriptionSummary: 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...


  • Tyler, Texas, United States Christus Health Full time

    Job 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...


  • Tyler, Texas, United States Christus Health Full time

    Job Summary:We are seeking a highly skilled Clinical Resource Utilization Specialist II to join our team at Christus Health. This individual will play a vital role in evaluating the clinical appropriateness of patient care and ensuring efficient resource utilization within our healthcare settings.Responsibilities:Evaluate patient care plans to ensure they...


  • Tyler, TX, United States Christus Health Full time

    Description 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...


  • Tyler, TX, United States Christus Health Full time

    DescriptionSummary: 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...


  • Tyler, TX, United States Christus Health Full time

    DescriptionSummary: 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...


  • Tyler, Texas, United States Christus Health Full time

    Job 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...

  • Nurse Case Manager

    3 weeks ago


    Tyler, Texas, United States Christus Health Full time

    As 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...

  • Nursing Unit Manager

    2 weeks ago


    Tyler, Texas, United States Christus Health Full time

    About 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...


  • Tyler, Texas, United States Christus Health Full time

    At Christus Health, we are seeking a highly skilled Clinical Utilization Specialist to join our team. As a key member of our acute care management department, you will play a critical role in evaluating the clinical appropriateness of patient care and ensuring optimal utilization of hospital resources.About the Role:The successful candidate will be...


  • Tyler, Texas, United States Christus Health Full time

    Estimated 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...


  • Tyler, Texas, United States Christus Health Full time

    Job 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...


  • Tyler, Texas, United States Christus Health Full time

    Job 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...


  • Tyler, Texas, United States Christus Health Full time

    Job 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...