Utilization Management Registered Nurse

Job Description: Ascension Texas Utilization Management Department (Fully Remote)Job Summary:• Provides health care services regarding admissions, case management, discharge planning and utilization review.Responsibilities:• Reviews admissions and service requests within assigned unit for prospective, concurrent and retrospective medical necessity and/or compliance with reimbursement policy criteria. Provides casemanagement and/or consultation for complex cases.• Assists departmental staff with issues related to coding, medical records/documentation, precertification, reimbursement and claim denials/appeals.• Assesses and coordinates discharge planning needs with healthcare team members.• May prepare statistical analysis and utilization review reports as necessary.• Oversees and coordinates compliance to federally mandated and third party payer utilization management rules and regulations.Complexity of Work:• Within scope of job, requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment.

Unit Description: Centralized Utilization Management departmentHigh level overview of the department: Centralized acute admission utilization review across 13 acute care and critical access hospitalsWhat type of unit: Utilization ManagementNumber of beds on the unit: NAAncillary staff and charge: Utilization Management Assistance, UM Managers: Pam Long, Jennifer LilesScrub color: NAWhat other units they could/will float to: NAWhat type of EMR is used: Cerner with Careport (Allscripts)Required Skills/Experience: Licensed RN (multistate or TX RN), 2 years acute care UM experience (or equivalent). Proficiency with InterQual/MCG and CMS regulations.Preferred Skills/Experience (if any): Use of payor portals, familiarity with managed Medicare and Medicaid insurers, Google Workspace, remote work experienceOther Proficient and adaptable with multiple technologies simultaneously