SWHRCIN UM REVIEWER RN SWHR CIN
Thanks for your interest in the SWHRCIN UM REVIEWER RN SWHR CIN position.
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Qualifications
- Associate's Degree Nursing Required
- Bachelor's Degree Nursing Preferred
- Master's Degree Nursing Preferred
- 3 Years Utilization management experience in an acute or post-acute provider, health plan or other care company experience Required AND
- 2 Years Experience in direct patient care as an RN, preferred acute care (ER, ICU, or Medical/ Surgical) Required
- 5 Years Experience in Health Plan Utilization Review, Discharge Planning and Medical Case Management Preferred
- RN - Registered Nurse Upon Hire Required
Position Responsibilities
- 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
Do you still have questions or concerns? Feel free to email your questions to recruitment@texashealth.org.