Utilization Management Nurse II
3 weeks ago
Job Summary:
The Utilization Management Nurse II at CHRISTUS Health plays a vital role in ensuring the clinical appropriateness of care provided to patients and optimizing hospital resource utilization. This position requires a skilled nurse to perform pre-admission, concurrent, and retrospective UM-related reviews and functions.
Key Responsibilities:
- Assess patient population for medical necessity, level of care, and appropriateness of setting and services.
- Utilize MCG/InterQual Care Guidelines and/or health system-approved tools to track impact and variance.
- 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.
- Facilitate joint decision-making with the interdisciplinary team regarding any changes in the patient status and/or negative outcomes in patient responses.
- Demonstrate, maintain, and apply current knowledge of regulatory requirements relative to the work process in order to ensure compliance.
- 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.
Requirements:
- 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.
- 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.
- RN License in state of employment or compact required.
- Certification in Case Management preferred.
Work Schedule: 8AM - 5PM Monday-Friday
Work Type: Full Time
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