Utilization Management Nurse II

3 weeks ago


Tyler, Texas, United States CHRISTUS Health Full time

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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