UT Southwestern Medical Center
PRN Utilization Review RN - M-F Days
UT Southwestern Medical Center, Dallas, Texas, United States, 75215
Overview
PRN Utilization Review RN - Monday - Friday Days at UT Southwestern Medical Center. Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations and documentation requirements. Responsibilities
Collaborates with Central Scheduling Department to provide accurate and complete clinical information to obtain authorization. Conducts admission reviews for Medicare and Medicaid beneficiaries as well as private insurance members and self-pay patients utilizing evidence-based guidelines. New admission reviews are done concurrently at the point of entry when the admission order is placed and necessary clinical information is available in the medical record. Communicate with admitting physicians and physician advisors when documentation does not appear to support hospital level of care. Use hospital approved medical necessity tool to determine level of care for inpatient or observation/outpatient services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two-midnight stay. Keeps current on all Federal, State and local regulatory changes that affect delivery or reimbursement of acute care services within the scope of Utilization Management. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Proactively collaborates with admitting physician to provide accurate level of care determination at the time of review. Escalates identified progression-of-care/patient flow barriers to appropriate departments. Actively participates in daily huddles, departmental meetings and education offerings. Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes. Educates members of the patient\'s care team on the appropriate access to and use of various levels of care. Promotes use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care. Serves as a resource person to physicians, care coordinators, physician offices and billing office for coverage and compliance issues. Completes all reviews within department established policies and best practice standards. Meets department quality standards as established for the department, e.g., Inter-rater Reliability audits and time frames. Performs other duties as assigned. Qualifications
Education:
Graduate of accredited nursing program and holds an active unrestricted RN license in the State of Texas. Experience:
5 years experience to include 2 years of clinical experience and minimum of 3 years of recent utilization review experience; prior experience with Epic CCM. Licenses:
Active unrestricted RN license in the State of Texas. Preferred
Experience in utilization review preferred. Job Duties
Acute care experience preferred. Collaborates with the Central Scheduling Department (CSD) team to provide accurate and complete clinical information in order to obtain authorization. Conducts admission reviews for Medicare and Medicaid beneficiaries as well as private insurance members and self-pay patients utilizing evidence-based guidelines. New admission reviews are done concurrently at the point of entry when the admission order is placed and necessary clinical information is available in the medical record. Communicate with admitting physicians and physician advisors when documentation does not appear to support hospital level of care. Use hospital approved medical necessity tool to determine level of care for inpatient or observation/outpatient services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two-midnight stay. Keeps current on all Federal, State and local regulatory changes that affect delivery or reimbursement of acute care services within the scope of Utilization Management. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Proactively collaborates with admitting physician to provide accurate level of care determination at the time of review. Escalates identified progression-of-care/patient flow barriers to appropriate departments. Actively participates in daily huddles, departmental meetings and education offerings. Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes. Educates members of the patient\'s care team on the appropriate access to and use of various levels of care. Promotes use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care. Serves as a resource person to physicians, care coordinators, physician offices and billing office for coverage and compliance issues. Completes all reviews within department established policies and best practice standards. Meets department quality standards as established for the department, e.g., Inter-rater Reliability audits and time frames. Performs other duties as assigned. Security and EEO
Security:
This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information. EEO:
UT Southwestern Medical Center is committed to equal opportunity and prohibits unlawful discrimination on basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status. Work Location:
Texas-Dallas, 5323 Harry Hines Blvd Job Type:
Standard;
Schedule:
Per Diem - PRN;
Shift:
Day Job;
Employee Status:
Regular
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PRN Utilization Review RN - Monday - Friday Days at UT Southwestern Medical Center. Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations and documentation requirements. Responsibilities
Collaborates with Central Scheduling Department to provide accurate and complete clinical information to obtain authorization. Conducts admission reviews for Medicare and Medicaid beneficiaries as well as private insurance members and self-pay patients utilizing evidence-based guidelines. New admission reviews are done concurrently at the point of entry when the admission order is placed and necessary clinical information is available in the medical record. Communicate with admitting physicians and physician advisors when documentation does not appear to support hospital level of care. Use hospital approved medical necessity tool to determine level of care for inpatient or observation/outpatient services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two-midnight stay. Keeps current on all Federal, State and local regulatory changes that affect delivery or reimbursement of acute care services within the scope of Utilization Management. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Proactively collaborates with admitting physician to provide accurate level of care determination at the time of review. Escalates identified progression-of-care/patient flow barriers to appropriate departments. Actively participates in daily huddles, departmental meetings and education offerings. Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes. Educates members of the patient\'s care team on the appropriate access to and use of various levels of care. Promotes use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care. Serves as a resource person to physicians, care coordinators, physician offices and billing office for coverage and compliance issues. Completes all reviews within department established policies and best practice standards. Meets department quality standards as established for the department, e.g., Inter-rater Reliability audits and time frames. Performs other duties as assigned. Qualifications
Education:
Graduate of accredited nursing program and holds an active unrestricted RN license in the State of Texas. Experience:
5 years experience to include 2 years of clinical experience and minimum of 3 years of recent utilization review experience; prior experience with Epic CCM. Licenses:
Active unrestricted RN license in the State of Texas. Preferred
Experience in utilization review preferred. Job Duties
Acute care experience preferred. Collaborates with the Central Scheduling Department (CSD) team to provide accurate and complete clinical information in order to obtain authorization. Conducts admission reviews for Medicare and Medicaid beneficiaries as well as private insurance members and self-pay patients utilizing evidence-based guidelines. New admission reviews are done concurrently at the point of entry when the admission order is placed and necessary clinical information is available in the medical record. Communicate with admitting physicians and physician advisors when documentation does not appear to support hospital level of care. Use hospital approved medical necessity tool to determine level of care for inpatient or observation/outpatient services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two-midnight stay. Keeps current on all Federal, State and local regulatory changes that affect delivery or reimbursement of acute care services within the scope of Utilization Management. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Proactively collaborates with admitting physician to provide accurate level of care determination at the time of review. Escalates identified progression-of-care/patient flow barriers to appropriate departments. Actively participates in daily huddles, departmental meetings and education offerings. Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes. Educates members of the patient\'s care team on the appropriate access to and use of various levels of care. Promotes use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care. Serves as a resource person to physicians, care coordinators, physician offices and billing office for coverage and compliance issues. Completes all reviews within department established policies and best practice standards. Meets department quality standards as established for the department, e.g., Inter-rater Reliability audits and time frames. Performs other duties as assigned. Security and EEO
Security:
This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information. EEO:
UT Southwestern Medical Center is committed to equal opportunity and prohibits unlawful discrimination on basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status. Work Location:
Texas-Dallas, 5323 Harry Hines Blvd Job Type:
Standard;
Schedule:
Per Diem - PRN;
Shift:
Day Job;
Employee Status:
Regular
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