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Clinical Utilization Review Nurse
1 month ago
As a Clinical Utilization Review Nurse at the University of Texas Southwestern Medical Center, you will play a critical role in ensuring the appropriate level of care for patients. You will conduct medical certification reviews for medical necessity, using nationally recognized guidelines to recommend the level of care to physicians. Your expertise will serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, and documentation requirements.
Responsibilities- Conduct inpatient admission reviews for Medicare and Medicaid beneficiaries, as well as private insurance members and self-pay patients, based on evidence-based guidelines.
- Collaborate with admitting physicians to provide coaching on accurate level of care determination at point-of-hospital entry.
- Identify and record information on any progression-of-care/patient flow barriers.
- Actively participate in daily huddles, multidisciplinary rounds, and patient care conferences to maintain knowledge about intensity of services and progression of care.
- Identify and record episodes of preventable delays or avoidable days due to failure of progression-of-care processes.
- Graduate of an accredited nursing program and holds an active unrestricted RN license in the State of Texas.
- Minimum of 5 years of experience, including 2 years of clinical experience and 3 years of recent Utilization Review experience.
- Current experience with utilizing a medical necessity tool to perform utilization reviews.
- Acute Care experience is preferred.
- Basic computer skills and knowledge.
- Prior experience with Epic CCM.
This is a remote-only position, and individuals who reside in the job will permanently work 100% from an alternate approved worksite.
UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.
