Utilization Review RN Case Manager (Onsite)

At Houston Methodist, the Utilization Review Nurse (URN) position is a licensed registered nurse (RN) who comprehensively conducts point of entry and concurrent medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, payer guidelines, CMS, and other state agencies. This position prospectively or concurrently determines the appropriateness of inpatient or observation services following review of relevant medical documentation, medical guidelines, and insurance benefits and communicates information to payers in accordance with contractual obligations. The URN position serves as a resource to the physicians and provides education and information on resource utilization and national and local coverage determinations (LCDs & NCDs). This position collaborates with case management in the development and implementation of the plan of care and ensures prompt notification of any denials to the appropriate case manager, denials, and pre-bill team members, as well as management.

FLSA STATUS
Exempt

QUALIFICATIONS

EDUCATION

• Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section
• Bachelor’s degree preferred

EXPERIENCE

• Three years of hospital clinical nursing experience

LICENSES AND CERTIFICATIONS
Required

• RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)

SKILLS AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations
• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
• Progressive knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and knowledge of local and national coverage determinations
• Recent work experience in a hospital or insurance company providing utilization review services
• Knowledge of Medicare, Medicaid, and Managed Care requirements
• Progressive knowledge of community resources, health care financial and payer requirements/issues, and eligibility for state, local, and federal programs
• Progressive knowledge of utilization management, case management, performance improvement, and managed care reimbursement
• Ability to work independently and exercise sound judgment in interactions with physicians, payers, and health care team members
• Strong assessment, organizational, and problem-solving skills
• Maintains level of professional contributions as defined in Career Path program
• Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44)

ESSENTIAL FUNCTIONS

PEOPLE ESSENTIAL FUNCTIONS

• Establishes and maintains effective professional working relationships with patients, families, interdisciplinary team members, payers, and external case managers; listens and responds to the ideas of others.
• Collaborates with the access management team to ensure accurate and complete clinical and payer information. Educates members of the patient’s healthcare team on the appropriate access to and use of various levels of care.
• Contributes towards improvement of department scores for employee engagement, i.e., peer-to-peer accountability.

SERVICE ESSENTIAL FUNCTIONS

• Pro-actively participates as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patient’s preference, reason for admission, and availability of resources. Participates in daily Care Coordination Rounds and identifies and communicates barriers to efficient utilization.
• Reviews H&Ps and admitting orders of all direct, transfer, and emergency care patients designated for admission to ensure compliance with CMS guidelines regarding appropriateness of level of care.
• Identifies potentially unnecessary services and care delivery settings and recommends alternatives, if appropriate, by analyzing clinical protocols.
• Escalates appropriate cases to the Physician Advisor (or services) for appropriate second level review, peer-peer discussions, and payer denial- appeal needs. Consults with physician advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Participates in quality improvement activities as stewards for resource utilization as it pertains to medical necessity and level of care. Promotes medical documentation that accurately reflects intensity of services, quality and safety indicators and patient’s need to continue stay.
• Promotes the use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care. Identifies areas for improvement based on an understanding of evidence-based practice/performance improvement projects based on these observations.
• Identifies and records episodes of preventable delays or avoidable days due to failure of the progression of the care process

FINANCE ESSENTIAL FUNCTIONS

• Contributes to meeting department financial targets, with a focus on appropriate utilization and denial prevention. Utilizes resources with cost effectiveness and value creation in mind. Self-motivated to independently manage time effectively and prioritize daily tasks, assisting coworkers as needed.
• Performs review for medical necessity of admission, continued stay and resource use, appropriate level of care, and program compliance using evidence-based, nationally recognized guidelines. Manages assigned patients and communicates and collaborates with the case manager to assist with appropriate interventions to avoid denial of payment.
• Collaborates with the revenue cycle regarding any claim issues or concerns that may require clinical review during the pre-bill, audit, or appeal process.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Identifies and presents areas for improvement in patient care or department operations and offers solutions by participating in department projects and activities.
• Seeks opportunities to identify self-development needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an ongoing basis.

SUPPLEMENTAL REQUIREMENTS
WORK ATTIRE

• Uniform: No
• Scrubs: No
• Business professional: Yes
• Other (department approved): No

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.

• On Call* Yes

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area No

QUALIFICATIONS

EDUCATION

• Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section
• Bachelor’s degree preferred

EXPERIENCE

• Three years of hospital clinical nursing experience

LICENSES AND CERTIFICATIONS
Required

• RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)