SWHRCIN UM REVIEWER RN SWHR CIN

📁
RN/Registered Nurse
📅
21009918 Requisition #
📅
342 Total Views
Thanks for your interest in the SWHRCIN UM REVIEWER RN SWHR CIN position. Unfortunately this position has been closed but you can search our 6 open jobs by clicking here.

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

My Profile

Create and manage profiles for future opportunities.

Go to Profile

My Submissions

Track your opportunities.

My Submissions

Similar Listings

Dallas, Texas, United States

📁 RN/Registered Nurse

Requisition #: 24001336