RN Utilization Management Reviewer - (REMOTE) SWHR CIN-Weekend hours/Shift Flexibility
Thanks for your interest in the RN Utilization Management Reviewer - (REMOTE) SWHR CIN-Weekend hours/Shift Flexibility position.
Unfortunately this position has been closed but you can search our 12 open jobs by clicking here.
Qualifications
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Associates Degree Nursing Required OR
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Bachelors or Master Degree Nursing Preferred
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3 years Utilization Management experience in an Acute or Post-Acute Provider, Health Plan or other Care Company experience (required)
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2 years’ experience in Direct Patient Care as an RN, preferred Acute Care (ER, ICU, or Medical/Surgical) (required)
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1 year Prior Authorization or Home Health experience (strongly preferred)
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5 years’ experience in Health Plan Utilization Review, Discharge Planning and Medical Case Management (preferred)
Position Responsibilities SWHR Utilization Management Reviewer RN supports the Collaborative Care Management Model as a working partner with physicians, social workers, pharmacists and other professional staff. Accurately applies decision support criteria. Demonstrates proficiency with caseload assignment and ability to manage complex cases effectively. Demonstrates an understanding of funding resources, services and clinical standards and outcomes. Demonstrates knowledge of case management standards of practice and processes including identification and assessment, planning, interventions and evaluation. Demonstrates a solid understanding of managed care trends, Medicare, and Medicaid regulations, reimbursement and the effect on utilization and outcomes of the different methods of reimbursement. Demonstrates the ability to develop departmental interfaces with internal and external customers to provide exemplary service and achieve goals. Demonstrates participation in multi-disciplinary team rounds if designated to cover a facility designed to address utilization/resource and progression of care issues. Assists in developing and implement an improvement plan to address issues. Implement discharge plan to prevent avoidable days or delays in discharge. Transition patient to next level of care in coordination with facility Discharge Planner. Identify and refer complex risk members to case management.
Complete documentation timely, completely, and accurately in accordance with: (a) eligibility and benefits (b) clinical guidelines/criteria (c) legal and regulatory requirements. Identify documents and refer cases to the UM Team Leader for medical review when services do not meet medical necessity criteria, and/or appropriate level of care, and/or potential quality issues. Maintains objectivity in decision making, utilizing facts to support decisions. Supports the mission statement, policies and procedures of the organization. Assists in eliminating boundaries to achieve integrated, efficient and quality service. Achieves ongoing compliance with all regulatory agencies Serves as a resource to employees and customers as demonstrated by visibility and knowledge of issues. Reviews and adheres to department policies and the Utilization Management Plan and Case Management program specific requirements. Completes interdepartmental education. Utilizes resources efficiently and effectively. Maintains safe environment. Participates in Performance Improvement activities.
Complete documentation timely, completely, and accurately in accordance with: (a) eligibility and benefits (b) clinical guidelines/criteria (c) legal and regulatory requirements. Identify documents and refer cases to the UM Team Leader for medical review when services do not meet medical necessity criteria, and/or appropriate level of care, and/or potential quality issues. Maintains objectivity in decision making, utilizing facts to support decisions. Supports the mission statement, policies and procedures of the organization. Assists in eliminating boundaries to achieve integrated, efficient and quality service. Achieves ongoing compliance with all regulatory agencies Serves as a resource to employees and customers as demonstrated by visibility and knowledge of issues. Reviews and adheres to department policies and the Utilization Management Plan and Case Management program specific requirements. Completes interdepartmental education. Utilizes resources efficiently and effectively. Maintains safe environment. Participates in Performance Improvement activities.
In addition to the required qualifications, a successful Utilization Management Reviewer RN will:
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experience and knowledge of Milliman Guidelines or similar clinical guidelines preferred
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strong analytical and organizational skills
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working knowledge and ability to apply professional standards of practice in work environment
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knowledge of specific regulatory, managed care requirements, and strong attention to detail
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working knowledge of computers and basic software applications used in job functions such as word processing, graphics, databases, spreadsheets, etc
Why Southwestern Health Resources
As a Southwestern Health Resources you’ll enjoy: comprehensive benefits, including a 401(k) with match; paid time off; competitive health insurance choices; healthcare and dependent care spending account options; wellness programs to keep you and your family healthy; tuition reimbursement; a student loan repayment program; and more.
As a Southwestern Health Resources you’ll enjoy: comprehensive benefits, including a 401(k) with match; paid time off; competitive health insurance choices; healthcare and dependent care spending account options; wellness programs to keep you and your family healthy; tuition reimbursement; a student loan repayment program; and more.
Moving healthcare forward
At the heart of SWHR are people who help people. We care about those we serve and each other. To be the national leader in providing population-based healthcare, our more than 850 employees use their knowledge, data insights and clinical experience to deliver care to the right patient, at the right time and in the right setting. By connecting physicians to patients and clinical insights to better outcomes, SWHR lowers costs, optimizes value, and builds a better healthcare system for all.
At the heart of SWHR are people who help people. We care about those we serve and each other. To be the national leader in providing population-based healthcare, our more than 850 employees use their knowledge, data insights and clinical experience to deliver care to the right patient, at the right time and in the right setting. By connecting physicians to patients and clinical insights to better outcomes, SWHR lowers costs, optimizes value, and builds a better healthcare system for all.
We invite you to learn more about us at www.southwesternhealth.org.
Let’s move healthcare forward – together.
Highlights:
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Combining the strengths of UT Southwestern Medical Center, Texas Health Resources and more than 2,500 community physicians, we offer the largest provider network in North Texas. SWHR covers approximately 700,000 patient members across 16 counties in North Texas.
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SWHR is the parent organization of Care N’ Care Insurance Co., a leading regional Medicare Advantage health plan organization that serves approximately 17,000 patients in North Texas.
Additional perks of being a SWHR Utilization Management Reviewer RN
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Gain a sense of accomplishment by contributing in a teamwork environment
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Positively impact patients’ quality of life
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Receive excellent mentorship, comprehensive training and dedicated clinical leadership resources
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Enjoy opportunities for growth
Explore Southwestern Health Resources Careers for more information and to search all career opportunities.
Our Recruitment team invites you to contact us with any questions at recruitment@texashealth.org.