Utilization Review Nurse

About Us Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well. Our Core Values Are We serve faithfully by doing what's right with a joyful heart. We never settle by constantly striving for better. We are in it together by supporting one another and those we serve. We make an impact by taking initiative and delivering exceptional experience. Benefits Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include: Immediate eligibility for health and welfare benefits 401(k) savings plan with dollar-for-dollar match up to 5% Tuition Reimbursement PTO accrual beginning Day 1 Note: Benefits may vary based upon position type and/or level. Job Summary Are you seeking an impactful nursing role? As a Utilization Review RN, review cases to determine medical suitability for insured patients. Your expertise shines through meticulous clinical reviews using established criteria. You play a key role in supporting the healthcare team by optimizing resources and implementing care plans. Communication with health plan departments is important to ensure services meet medical necessity standards. This includes prospective, concurrent, and retrospective reviews. Essential Functions Of The Role You will review all cases. Use medical guidelines to evaluate services. Understand patient needs. Resolve complex matters when necessary. Confirm admission status is correct. Collaborate with Utilization Review coordinators when needed. You will communicate with insurance. Talk to doctors about patients. Make sure needed paperwork is completed. You’ll report insurance company issues to leadership. Identify and communicate quality assurance or risk management issues promptly when they arise. You will help improve our processes by evaluating, developing, and implementing protocols, policies, and procedures. Key Success Factors Comprehensive understanding of diverse healthcare techniques, practices, and industry-related language. Proficiency in customer engagement, ensuring their concerns are heard and promptly addressed. Thorough understanding of discharge planning, care coordination, utilization assessment and care levels. Knowledge of local and national regulations is needed, like those from the Department of Insurance and Department of Labor. Centers for Medicare and Medicaid Services, Health and Human Services Commission, and National Committee for Quality Assurance are also important. Exceptional communication skills, including articulating thoughts clearly in speech and writing. Personable, with the ability to interact effectively with a diverse range of stakeholders. Problem-solving capability, equipped with critical thinking skills. Ability to juggle multiple tasks and work under time pressures. Belonging Statement We believe that all people should feel welcomed, valued and supported. Qualifications Associate degree. Prior experience of at least (3) three years in the nursing field. Must have a valid nursing registration (RN). #J-18808-Ljbffr