PRN Utilization Management Review Nurse

Overview Job Number: 178950, Job Title: PRN Utilization Management Review Nurse, Salary: $47.37 - $57.80 Harris Health System is the public healthcare safety-net provider established in 1966 to serve the residents of Harris County, Texas. As an essential healthcare system, Harris Health champions better health for the entire community, with a focus on low-income uninsured and underinsured patients, through acute and primary care, wellness, disease management and population health services. Ben Taub Hospital (Level 1 Trauma Center) and Lyndon B. Johnson Hospital (Level 3 Trauma Center) anchor Harris Health's robust network of 39 clinics, health centers, specialty locations and virtual (telemedicine) technology. Harris Health is among an elite list of health systems in the U.S. achieving Magnet(r) nursing excellence designation for its hospitals, the prestigious National Committee for Quality Assurance designation for its patient-centered clinics and health centers and its strong partnership with nationally recognized physician faculty, residents and researchers from Baylor College of Medicine; McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth); The University of Texas MD Anderson Cancer Center. Responsibilities The Utilization Management Review Nurse (UMRN) performs technical and administrative work to evaluate the necessity, appropriateness, and efficiency of the utilization of medical services procedures and facilities. Support the health system by using clinical knowledge, industry-standard clinical guidelines, and responsibility for ensuring care is provided at the appropriate level of care based on medical necessity. Promote quality care and cost-effective outcomes to enhance the physical, psychosocial and vocational health of individuals, partnering with Care Management, Physician Advisors, Finance, and 3rd party payers. Work with payers to reconcile denials and reconsiderations, assist with appeals as needed, and arrange peer-to-peer level review while collecting, analyzing and addressing variances from the plan of care/care path with the physician and/or other members of the healthcare team. Participate in quality improvement activities, exemplify professionalism, and promote a customer-friendly environment by utilizing ServiceFIRST behaviors in interactions with Harris Health team members, payer vendors, and physicians. Minimum Qualifications Degrees: Graduated from an accredited school of Nursing with a Bachelors in Nursing. Licenses & Certifications: Registered Nurse: Licensed to practice nursing in the State of Texas. Case Management Certification (ACM or CCM) within two years of hire. Basic Life Support: American Heart Association (AHA) or Red Cross approved program. Work Experience: 5 Years of Experience: Strong clinical background in a variety of acute healthcare settings including 2 years in Case Management, Quality Management, Utilization Management, or Coding. Communication Skills: Above Average Verbal Communication (Heavy Public Contact); Exceptional Verbal (Public Speaking); Writing/Correspondence; Writing/Reports. Language: Bilingual Skills (Preferred). Proficiencies: MS Word; PC; MS Excel; MS PowerPoint. Job Attributes Knowledge/Skills/Abilities: Analytical; Mathematics; Medical Terms; Utilization review tools: MCG and/or Change Healthcare (InterQual). Work Schedule: Flexible: 8 hour shifts as per system need; variable to 10-12 as needed. Weekends: Depends on needs of system. Telecommute. Holidays: Depends on needs of system. Other Special Requirements Equipment Operated: Standard office equipment, computer software, etc. #J-18808-Ljbffr