Registered Nurse Utilization Review Specialist
4 days ago
As a Registered Nurse Utilization Review Specialist at the University of Texas Southwestern Medical Center, you will play a critical role in ensuring the delivery of high-quality, cost-effective patient care. Your expertise will be utilized to conduct medical necessity reviews for acute care services, utilizing evidence-based guidelines to recommend the most appropriate level of care.
Key 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 the access management team to provide accurate and complete clinical information for authorization purposes.
- Use InterQual Level of Care Criteria to determine the appropriateness of inpatient level of care or observation services.
- Confers with admitting physicians to offer suggestions for clarity and completeness of documentation.
- Identify and record information on any progression-of-care/patient flow barriers.
- 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.
- Educate members of the patient's care team on the appropriate access to and use of various levels of care.
- Serve as a resource person to physicians, care coordinators, physician offices, and billing office for coverage and compliance issues.
- 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 the individual will work 100% from an alternate approved worksite. Any qualifications to be considered as equivalents in lieu of stated minimums require prior approval of the Vice President for Human Resources Administration, or his/her designee.
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