Utilization Management (UM) Reviewer RN - Utilization Management - Southwestern Health Resources (SWHR)

Here’s What You Need

Education

• Associate’s degree in Nursing required.
• Bachelor’s degree in Nursing or Master’s degree in Nursing preferred.

Experience

• Require 2 years of Utilization Management experience in an acute or post-acute provider, health plan or other care company.
• Require 2 years of direct patient care experience as an RN, in an acute care setting, especially in ER, ICU, or Medical/ Surgical unit.
• Prefer 5 years of experience in Health Plan Utilization Review, Discharge Planning and Medical Case Management.
• Prefer 1 year of Prior Authorization or Home Health experience.

Licenses & Certifications

• Current and active State of Texas Registered Nurse (RN) License upon hire required. 

Skills & Abilities

• Experience and knowledge of Milliman Guidelines or similar clinical guidelines preferred.
• Strong analytical and organizational skills.
• Working knowledge and ability to apply professional standards of practice in work environment.
• Knowledge of specific regulatory, managed care requirements, and strong attention to detail.
• Working knowledge of computers and basic software applications used in job functions such as word processing, graphics, databases, spreadsheets, etc. 

What You Will Do

Position Responsibilities

The Utilization Management (UM) Reviewer RN is accountable for performing initial, concurrent, or post service review activities, discharge care coordination, and assisting with efficiency and quality assurance of medical necessity reviews in alignment with Federal, State, Plan, and Accreditation standards. The UM Reviewer serves as a liaison between providers/ facilities and Care Management Division.

Position Functions

• 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.

Why Southwestern Health Resources 

As a Southwestern Health Resources employee, 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.

• Additional perks of being an SWHR employee:
• Gain a sense of accomplishment by contributing to a teamwork environment.
• Positively impact patients’ quality of life.
• Receive excellent mentorship, comprehensive training and dedicated clinical and administrative leadership resources.
• 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

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