Texas Health Resources
Employee, Part-Time, Alternative Schedule, Occasional
Arlington, TX Candidates need to be able to work in the City or State specified – Telecommute
Title: Clinical Review Utilization Manager – Registered Nurse – PRN – Remote
Location: Arlington US-TX US
Job Type: PERMANENT
Job Time: FULLTIME
Job Description: Texas Health Resources is seeking to hire a Clinical R eview Utilization Manager Registered Nurse for our Clinical Review Department.
This is a remote position employee will be able to work from home. Orientation will be held at the Chase Building – 500 East Border Street, Arlington, Texas 76010.
Salary range is $35.48/hour – Max $49.18/hour – based on relevant experience.
PRN – Schedule varies, rotating weekends, 4 weekend shifts required in a 6 weeks schedule.
The Clinical Review Utilization Manager is responsible for determining initial admission status and level of care recommendations for inpatient admissions, observation and outpatient admissions for any hospital in the THR system. The essential job functions for this position are :
Conduct initial admission review of inpatient, observation and outpatient admissions (commercial insurance, Medicare Advantage and self-pay) according to established criteria set adopted by System. Conduct initial admission review of inpatient, observation and outpatient admissions with traditional Medicare for compliance with the New IPPS rule.
Provide clinical information to payors as needed for completion of pre-certification process.
Ensure proper authorization requirements are met with each admission. Obtains or ensures acquisition of appropriate precertification’s/ authorizations from third party payers and placement to appropriate level of care prior to hospitalization or upon admission utilizing medical necessity criteria and third party payer guidelines.
Obtains, or facilitates, acquisition of urgent/emergent authorizations, continued stay authorizations, as needed and with compliance with all regulatory and contractual requirements.
Maintains a working knowledge of care management, utilization review changes, authorization changes, contract changes, regulatory requirements, etc.
Adheres to the policies, procedures, rules, regulations, and laws of the hospital and federal and state regulatory bodies.
Communicates and collaborates with the CBO and medical records to render appropriate information needed to secure reimbursement.
Provide consultation to medical and nursing staff, health information management, and payors on potential issues with reimbursement of hospitalization.
Evaluate concurrent potential denials or payment issues and initiate communication with admitting physician to assure proper documentation for selected admission status.
Collaborates and communicates with payor via phone, fax or computer system per payor contract.
Initiates and facilitates physician communications relative to the UR process when indicated. Assists and facilitates the physician peer-to-peer review process with insurance medical directors as indicated.
Communicates payer issues and medical necessity concerns with members of the health care team.
Escalate incorrect status concerns to UM manager.
Determines working DRG with each initial review via Canopy, or other Care Management tool. Discusses working DRG issues as needed with Care Transition Manager.
Performs other duties as assigned.
The ideal candidate will possess the following qualifications :
Associate’s Degree in Nursing required.
Bachelor’s Degree in Nursing preferred.
5 years inpatient clinical nursing experience in an acute hospital setting required.
1 year Utilization Management required.
Experience in case management, and/or the application of medical necessity criteria preferred
Milliman Care Guidelines preferred
Registered Nurse License to practice professional nursing in the state Texas required.
Specialty certification preferred.
Requires interpersonal, analytic, and critical thinking skills for problem sol…
Medical & Health , Nursing