Utilization Review Specialist Nurse

At Houston Methodist, the Utilization Review Specialist Nurse (URSN) position is a licensed registered nurse (RN) who comprehensively conducts point of entry and concurrent medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, payer guidelines, CMS, and other state agencies. In addition to performing the duties of the URN, this position is able to cover a multitude of utilization review functions through point of entry, observation progression of care management, concurrent review and denials reviews. Additionally, the URSN will prospectively or concurrently determines the appropriateness of inpatient or observation services following review of relevant medical documentation, medical guidelines, and insurance benefits and communicates information to payers in accordance with contractual obligations. The URSN position serves as a resource to the physicians and provides education and information on resource utilization and national and local coverage determinations (LCDs & NCDs). This position collaborates with case management in the development and implementation of the plan of care and ensures prompt notification of any denials to the appropriate case manager, denials, and pre-bill team members, as well as management. The URSN position helps drive change by identifying areas where performance improvement is needed (e.g., day-to-day workflow, education, process improvements).

PEOPLE ESSENTIAL FUNCTIONS

• Collaborates with the physician and all members of the interprofessional health care team to facilitate care and communication with payers, and external case managers. Intervenes, as necessary, to ensure the plan of care and services provided are patient-focused, high-quality, efficient, and cost-effective. Serves as a preceptor and implements staff education specific to patient populations and unit processes, coaches and mentors other staff and students.
• Serves as a resource for the department and hospital. Provides education to physicians, nurses, and other health care providers on utilization management topics.
• Initiates improvement of department scores for employee engagement, i.e., peer-to-peer accountability.

SERVICE ESSENTIAL FUNCTIONS

• Performs review for medical necessity of admission, continued stay, and resource use, appropriate level of care and program compliance. Identifies when services no longer meet evidence-based criteria, initiates discussions with attending physicians, coordinates with external utilization review teams to facilitate efficient use of resources and seeks assistance from the Physician Advisor when necessary. Informs management of the possible need for issuing Medical Hospital Issued Notices of Non-Coverage and Advance Beneficiary Notices of Non-Coverage.
• Applies approved utilization criteria to monitor appropriateness of admissions, level of care, resource utilization, and continued stay. Reviews level of care denials to identify trends and collaborates with team to recommend opportunities for process improvement.
• Promotes medical documentation that accurately reflects intensity of services, quality and safety indicators and patient's need to continue stay. Identifies potentially unnecessary services and care delivery settings and recommends alternatives, if appropriate, by analyzing clinical protocols. Reviews H&Ps and admitting orders of all direct, transfer, and emergency care patients designated for admission to ensure compliance with CMS guidelines regarding appropriateness of level of care.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Proactively takes action to achieve continuous improvement and expedite care/facilitate discharge.
• Identifies and records episodes of preventable delays or avoidable days due to failure of the progression of care process.
• Conducts chart audits and performs peer-to-peer evaluations for continuous quality improvement.

FINANCE ESSENTIAL FUNCTIONS

• Identifies population and/or service-specific trends impacting utilization and addresses/resolves issues impeding patient progression of care. Contributes to meeting department and hospital financial targets.
• Manages all patients in Observation, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital.
• Collaborates with revenue cycle regarding any claim issues or concern that may require clinical review during the pre-bill, audit, or appeal process.
• Secures reimbursement for hospital services by communicating medical information required by all external review entities, managed care contracts, insurers, fiscal intermediaries, state, and federal agencies. Responds to requests for information, monitors covered days, initiates review to ensure that all days are covered and reimbursable.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Identifies opportunities for practice change. Promotes use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care. Offers innovative solutions through evidence-based practice/performance improvement projects and shared governance activities.
• Seeks opportunities to identify self-development needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an ongoing basis.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

EDUCATION

• Bachelor's degree or higher from an accredited school of Nursing
• Master's degree preferred

WORK EXPERIENCE

• Five years of hospital clinical nursing experience, which includes three years in utilization review and/or case management

LICENSES AND CERTIFICATIONS - REQUIRED

• RN - Registered Nurse - Texas State Licensure - Compact Licensure - Must obtain permanent Texas license within 60 days (if establishing Texas residency) AND
• Magnet ANCC-recognized Case Management certification: ACHPN-HPCC or CCM or CMC or ACM-NBCM or CDCES or CHPN-HPCC or CMGT-BC or CM-ABOHN or CMCN or ANCC-NCM

KNOWLEDGE, SKILLS, AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations
• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
• Expert knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and knowledge of local and national coverage determinations
• Comprehensive knowledge of Medicare, Medicaid, and Managed Care requirements
• Comprehensive knowledge of community resources, health care financial and payer requirements/issues, and eligibility for state, local, and federal programs
• Comprehensive knowledge of utilization management, case management, performance improvement, and managed care reimbursement
• Ability to work independently and exercise sound judgment in interactions with physicians, payers, and health care team members
• Strong assessment, organizational, and problem-solving skills
• Maintains level of professional contributions as defined in Career Path program
• Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44)
• Competent computer skills of the entire Microsoft Office Suite (Access, Excel, Outlook, PowerPoint, and Word

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

ON-CALL*

• Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below.

• On Call* Yes

TRAVEL**

**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area No

Company Profile:

Houston Methodist Hospital is recognized by U.S. News & World Report as the No. 1 hospital in Texas and one of America's "Best Hospitals." As a full-service, acute-care hospital located in the Texas Medical Center and the flagship hospital of Houston Methodist, it has evolved into one of the nation's largest nonprofit teaching hospitals and a leader in innovative medical research with a comprehensive residency program. Two of Houston Methodist's primary academic affiliates are among the nation's leading health care organizations: Weill Cornell Medicine and New York-Presbyterian Hospital. Houston Methodist also has affiliations with Texas A&M University and the University of Houston. With 948 operating beds, 85 operating rooms and more than 8,400 employees, Houston Methodist Hospital offers unparalleled care for thousands of patients from around the world.

Houston Methodist is an Equal Opportunity Employer.