The Utilization Management Review Nurse (UMRN) performs technical and administrative work required to evaluate the necessity, appropriateness, and efficiency of the utilization of medical services procedures and facilities. This role supports the health system by utilizing clinical knowledge, expertise and industry standard clinical guidelines carrying the responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. The UMRN promotes quality care and cost-effective outcomes to enhance the physical, psychosocial and vocational health of individuals, partnering with Care Management, Physician Advisors, Finance, and 3rd party payers to deliver the best holistic outcomes for all patients. This position will work with payers to reconcile denials and reconsiderations, assist with appeals as needed and arrange peer to peer level review while collecting, analyzing and addressing variances from the plan of care/care path with physician and/or other members of the healthcare team.
The UMRN participates in quality improvement activities, exemplifies professionalism, and promotes a customer-friendly environment by utilizing ServiceFIRST behaviors in interactions with Harris Health team members, payer vendors, and physicians.
Minimum Qualifications
Degrees: - Graduated from an accredited school of Nursing with a Bachelors in Nursing.
Licenses & Certifications: - Registered Nurse: Licensed to practice nursing in the State of Texas. - Case Management Certification (ACM or CCM) within two years of hire. - Basic Life Support: American Heart Association (AHA) or Red Cross approved program.
Work Experience: - 5 Years of Experience: Strong clinical background in a variety of acute healthcare settings including 2 years in Case Management, Quality Management, Utilization Management, or Coding.
Communication Skills: - Above Average Verbal Communication (Heavy Public Contact) - Exceptional Verbal (Public Speaking) - Writing/ Correspondence - Writing/ Reports
Language: - Bilingual Skills (Preferred)
Proficiencies: - MS Word - PC - MS Excel - MS PowerPoint
Job Attributes
Knowledge/Skills/Abilities: - Analytical - Mathematics - Medical Terms - Other: Utilization review tools: MCG and or Change healthcare (Interqual)
Work Schedule: - Flexible: 8 hour shifts as per system need; variable to 10-12 as needed. - Weekends: Depends on needs of system. - Telecommute - Holidays: Depends on needs of system.
Other Special Requirements
Equipment Operated: Standard office equipment, computer software, etc.
The Harris Health System is a fully integrated healthcare system that cares for all residents of Harris County, Texas. We are the first accredited healthcare institution in Harris County to be designated by the National Committee for Quality Assurance as a Patient-Centered Medical Home, and are one of the largest systems in the country to achieve the quality standard. Our system includes 23 community health centers, five school-based clinics, a dental center and dialysis center, mobile health units, a rehabilitation and specialty hospital and two full-service hospitals.Ben Taub Hospital is a world renowned Level I Trauma Center with 586 licensed acute-care beds and provides a wide range of specialty care outpatient services. Lyndon B. Johnson Hospital is a 328 licensed bed acute-care hospital with a newly expanded Level III trauma center and a distinguished regional center for neonatal intensive care for high-risk deliveries.Harris Health is a teaching system for Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth). We train the next generation of healthcare providers on the latest medical procedures and technological breakthroughs.With... our fully integrated electronic medical records system, we offer patients the convenience and assurance that their medical history is accurate, safe and available when and where it is needed. Our Medical Home designation ensures that we offer a full range of preventive, specialty and acute care services for the entire family.