Utilization Management Nurse

Job Title & Specialty Area:
Utilization Management Nurse

Department:
Utilization Review

Location:
Dallas

Shift:
Day, M-F (This position does provide some flexibility in start/end time, and does require availability to be on campus for meetings)

Job Type:
Remote

At Children's Health, our mission is to Make Life Better for Children, and we recognize that their health plays a crucial role in achieving this goal.

Through our cutting-edge treatments and affiliation with UT Southwestern, we strive to deliver an extraordinary patient and family experience, ensuring that every moment, big or small, contributes to their overall well-being.

Our dedication to promoting children's health extends beyond our organization and encompasses the broader community.

Together, we can make a significant difference in the lives of children and contribute to a brighter and healthier future for all.

Summary:
The Utilization Management Nurse is responsible for determining and managing medical necessity of acute inpatient admissions utilizing clinical criteria. This includes communication with the Physician's admitting patients to a Children's Health System of Texas (CHST) facility and collaboration with the Physician Advisor during the review process.
Responsibilities:

• Accountable for current knowledge of utilization management responsibilities, including: payer information; business rules; regulatory guidelines; and policies and procedures.
• Performs initial, concurrent, discharge, and retrospective reviews on assigned caseload. Reviews inpatient medical necessity criteria utilizing Indicia or Interqual, CHST clinical pathways, and clinical knowledge to determine appropriateness of admission, level of care, and continued stay.
• Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health-care facility to comply with government and insurance company reimbursement policies: Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.
• Combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided.
• Maintains productivity and optimum case load, delegating appropriately to maximize skills set, productivity and effectiveness.
• Collaborates with Patient Access Services as it relates to inpatient authorization, predetermination, pre/prior authorization, and status changes.
• Communicates with Commercial or MMC (Medicaid Managed Care) payers to certify inpatient days as required.

Utilizes various methods to obtain necessary information:
telephone, fax, secure email, secure web portal. Removing completed cases from the Midas worklist.

• Maintain accurate documentation of all communication and interventions in EMR.
• Escalate payer problems to UM RN II or Denials Management Specialist
• Proactively intervenes with medical necessity, or level of care denials by exercising all real-time options to overturn decision. Actions include, but not limited to,

* requesting expedited appeal, use of third party Physician Advisor, facilitation of peer to peer with CHST Physician.

• Identifies issues and strategies to modify and/or enhance the utilization management program.
• Advances clinical expertise through attendance at in-hours education opportunities, reading journals, and attendance at conferences.
• Attends department/program meetings regularly.
• Maintains a level of productivity and quality consistent with: complexity of the assignment; facility policies and guidelines; established principles, ethics and standards of practice of professional nursing;
• Other job duties as assigned

WORK EXPERIENCE

• At least 4 years clinical nursing experience.

For those employees hired after 4/1/2022 experience must be in the following areas:
CCBD (Oncology), NICU, PICU, Heart Center (Cardiology, Pulmonary and/or Emergency Department) required

• At least 1 year Utilization Review or Case Management experience preferred
• Previous experience with Interqual or Milliman preferred

EDUCATION

• Four-year Bachelor's degree or equivalent experience Bachelor's of Nursing preferred
• Two-year Associate's degree or equivalent experience Associate's Degree of Nursing required required

LICENSES AND CERTIFICATIONS

• Registered Nurse required
• Accredited Case Manager (ACM) or Certified Case Manager (CCM) certification preferred

JOB PROFILE

• Requires in-depth professional knowledge and practical/applied expertise in own discipline and basic knowledge of related disciplines within the broader professional field
• Has knowledge of best practices and how own area integrates with others; demonstrates awareness of the industry, including regulatory, evolving customer demands, and the factors that differentiate the organization in the market
• Acts as a resource for colleagues with less experience; may lead projects with manageable risks and resource requirements
• Solves complex problems and takes a new perspective on existing solutions; exercises judgment based on the analysis of multiple sources of information
• Impacts a range of customer, operational, project or service activities within own team and other related teams; works within broad guidelines and policies
• Works independently, receives minimal guidance
• Explains difficult or sensitive information; works to build consensus

MANAGEMENT SKILLS

• Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
• Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
• Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
• Develop and use collaborative relationships to facilitate the accomplishment of work goals.
• Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
• Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
• Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
• Effectively manage one's time and resources to ensure that work is completed efficiently.
• Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
• Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self impose standards of excellence rather than having standards imposed.
• Assimilate and apply new job-related information in a timely manner.
• Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.

A Place Where You Belong

We put our people first. We welcome, value, and respect the beliefs, identities and experiences of our patients and colleagues.

We are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children's Health a place where everyone can contribute.

Holistic Benefits - How We'll Care for You:

• Employee portion of medical plan premiums are covered after 3 years.
• 4%-10% employee savings plan match based on tenure
• Paid Parental Leave (up to 12 weeks)
• Caregiver Leave
• Adoption and surrogacy reimbursement

As an equal opportunity employer, Children's Health does not discriminate against employees or applicants because of race, color, religion, sex, gender identity and expression, sexual orientation, age, national origin, veteran or military status, disability, or genetic information or any other Federal or State legally-protected status or class.

This applies to all aspects of the employer-employee relationship including but not limited to recruitment, hiring, promotion, transfer pay, training, discipline, workforce adjustments, termination, employee benefits, and any other employment-related activity.

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