Utilization Review RN

Responsibilities

Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.

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Job Summary: The Utilization Review (UR) Nurse (initial clinical reviewer) is a registered nurse (RN) or health professional (licensed practical nurse (LPN) or licensed vocational nurse (LVN)), who possesses an active, current, valid, and unrestricted professional license or certification recognized in the relevant jurisdiction, in States of Nevada, Texas, and/or Florida, or territory in the United States (U.S.) that the organization provides utilization management (UM) services, if the UR RN is reviewing clinical cases in that state. During the initial screening process, UR RNs are available to non-clinical administrative staff while non-clinical administrative staff perform initial screening. UR RN reviews and evaluates clinical cases for appropriateness against established criteria and published medical evidence. The UR Nurse, using clinical and operational knowledge, assesses needs, and coordinates resources within and outside the benefit plan to promote optimal health benefits and outcomes (both clinical and financial). Initial clinical reviewers have the appropriate clinical background to render decisions requiring clinical judgment and experience. The UR Nurse (initial clinical reviewer) may assist in the notification process for non-certifications. Initial clinical reviewers must have appropriate clinical support and do not issue non-certifications. The UR Nurse reviews requests for medical services and consults or refers to a Medical Director (licensed Doctor of Medicine or Doctor of Osteopathic Medicine; licensed health professional in the same licensure category as the ordering provider; or health professional with the same clinical education as the ordering provider in clinical specialties where licensure is not issued) for those clinical cases that require additional expertise. Measures and reviews performance outcomes, proposes, and implements improvement processes and system enhancements to achieve desired results. Identifies appropriate resources and demonstrates knowledge in managing each case and maintains accurate records and provides timely verbal and written reports as directed.

Benefit Highlights

• Loan Forgiveness Program
• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Career development opportunities within UHS and its 300+ Subsidiaries! More information is available on our Benefits Guest Website: benefits.uhsguest.com

About Universal Health Services: One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.

Qualifications

Qualifications and Requirements:

• Graduation from an accredited nursing education program. Bachelor’s degree from an accredited nursing education program, is preferred. Advance degrees such as MBA, MPH, master's in nursing, or advanced focused training is a definite plus.
• Current, unrestricted, active, and valid license recognized in the relevant jurisdiction to practice in the State of Nevada, Florida, and/or Texas as a Registered nurse (RN) or health professional (licensed practical nurse (LPN) or licensed vocational nurse (LVN)).
• If there is a restriction that is allowed by a relevant jurisdiction, according to the medical director or clinical director, it is of the type that does not affect the health professional’s ability to fulfill the roles and responsibilities of an initial clinical reviewer.
• Must be able to practice as a health professional in a state or territory of the United States.
• Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ) preferred.
• Minimum of three (3) years of Utilization Review/Case Management experience required.
• Recent (within past 3 years) working knowledge of Interqual criteria and/or Milliman Care Guidelines required.
• Minimum of three (3) years in clinical medical/surgical nursing practice within a hospital setting.
• Ability to expertly communicate in English, both verbally and in writing, bi-lingual in English and Spanish desired.
• Attention to detail with ability to prioritize, problem solve, and multi-task.
• Ability to quickly analyze and interpret data and write reports using standard medical terminology.
• Experience executing strategies and organizing and prioritizing multiple projects and relationships with key stakeholders and program implementers.
• Written and oral communication skills, including large and small group presentations, group facilitation and training.
• Ability to influence others and work collaboratively with key partners to achieve positive results.
• Ability to use relevant tools (e.g., word processing, spreadsheet, email and database programs and voicemail).
• Empathetic, Caring, Compassionate Listener.
• Excellent computer skills.
• Able to work with a diverse multicultural and socioeconomic population.
• Familiarity with health care delivery and/or health insurance programs.

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.