CHRISTUS Health
Utilization Management Nurse II - Case Management - Full Time
CHRISTUS Health, Beaumont, Texas, us, 77726
Utilization Management Nurse II – Case Management – Full Time
The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. The role performs a variety of pre‑admission, concurrent, and retrospective utilization management (UM) reviews. The Nurse competently and accurately utilizes approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services “CMS” Inpatient List), manages a diverse workload in a fast‑paced environment, and stays current on commercial and government payor policies and Joint Commission regulations.
Job Summary The Utilization Management Nurse collaborates with clinical professionals to communicate patient status, coordinate care transitions, and obtain necessary certifications from insurance providers. The Nurse works with the interdisciplinary team to ensure patient care aligns with regulatory requirements and the organization’s mission.
Responsibilities
Meet expectations of the OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
Apply clinical competency and judgment to perform comprehensive assessments and determine medical necessity criteria for the appropriate level of care.
Assess assigned patient population for medical necessity, level of care, and appropriateness of setting and services using MCG/InterQual Care Guidelines or other approved tools.
Use criteria sets for admission reviews, continued stay reviews, outlier reviews, and clinical appropriateness recommendations.
Coordinate and facilitate correct identification of patient status.
Analyze documentation quality and collaborate with the physician and treatment team to obtain needed documentation.
Facilitate joint decision‑making with the interdisciplinary team regarding changes in patient status and outcomes.
Maintain current knowledge of regulatory requirements to ensure compliance (e.g., IMM, Code 44).
Demonstrate adherence to CHRISTUS CORE values.
Identify, evaluate, and provide utilization review services, analyzing information supplied by physicians to make timely review determinations.
Take appropriate follow‑up action when utilization criteria are not met.
Proactively refer cases for medical necessity reviews, peer‑to‑peer reviews, and denial avoidance.
Collaborate with the Physician Advisor for secondary reviews.
Review patient status at admission to determine medical necessity of hospitalization and appropriate level of care or placement.
Review surgery schedules to ensure proper ordering and authorization of planned surgeries.
Review Observation status patients to determine acceptable discharge or conversion to inpatient status.
Identify and resolve issues regarding clinical appropriateness, coverage, and payor denials.
Maintain consistent communication with payors to coordinate certification of hospital services.
Coordinate and facilitate patient care progression throughout the continuum and document medical necessity at each level of care.
Evaluate care by the interdisciplinary team and advocate for standards of practice.
Analyze assessment data to identify potential problems and formulate care goals/outcomes.
Follow CHRISTUS HIPAA guidelines to protect PHI.
Attend scheduled department and interdepartmental meetings.
Demonstrate technology literacy across multiple systems.
Act as a catalyst for organizational change, responding with flexibility and teamwork.
Translate strategies into action steps; monitor progress; achieve results.
Demonstrate confidence, drive, and the ability to overcome challenges to achieve organizational goals.
Perform responsibilities in a manner that meets the specific needs of patients served.
Negotiate effectively with physicians, nursing staff, administrators, discharge planners, and payors.
Maintain strong verbal and written communication skills and knowledge of clinical protocols.
Adapt to frequently changing workloads and interruptions.
Work overtime or take calls as needed.
Travel to other facilities as required.
Participate in Multidisciplinary/Patient Care Progression Rounds.
Escalate cases per policy to Physician Advisors and/or CM Director.
Document in the medical record per regulatory and departmental guidelines.
Assist with special projects as requested.
Serve as a preceptor or orienter to new associates.
Assume responsibility for professional growth and development.
Familiarity with InterQual and MCG preferred.
Demonstrate excellent verbal and written communication for diverse populations.
Apply critical and analytical thinking skills.
Exhibit clinical competency.
Multitask and function in a stressful, fast‑paced environment.
Maintain knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
Understand pre‑acute and post‑acute levels of care and community resources.
Work independently and exercise sound judgment when interacting with physicians, payors, patients, and families.
Understand internal and external resources and community options.
Perform other duties as assigned.
Requirements & Qualifications
Graduated from an accredited School of Nursing or have at least five years of successful experience as a Utilization Management Nurse I at CHRISTUS Health.
At least two years of clinical experience, with at least one year in an acute care setting, or have proven success as a Utilization Management Nurse I at CHRISTUS Health.
RN license in the state of employment or a valid compact; LPN or LVN license accepted for associates with five or more years of demonstrated success in the UM Nurse I role.
Certification in Case Management preferred; BLS preferred.
Work Hours 8:00 AM – 5:00 PM, Monday‑Friday
Employment Type Full‑time
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Job Summary The Utilization Management Nurse collaborates with clinical professionals to communicate patient status, coordinate care transitions, and obtain necessary certifications from insurance providers. The Nurse works with the interdisciplinary team to ensure patient care aligns with regulatory requirements and the organization’s mission.
Responsibilities
Meet expectations of the OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
Apply clinical competency and judgment to perform comprehensive assessments and determine medical necessity criteria for the appropriate level of care.
Assess assigned patient population for medical necessity, level of care, and appropriateness of setting and services using MCG/InterQual Care Guidelines or other approved tools.
Use criteria sets for admission reviews, continued stay reviews, outlier reviews, and clinical appropriateness recommendations.
Coordinate and facilitate correct identification of patient status.
Analyze documentation quality and collaborate with the physician and treatment team to obtain needed documentation.
Facilitate joint decision‑making with the interdisciplinary team regarding changes in patient status and outcomes.
Maintain current knowledge of regulatory requirements to ensure compliance (e.g., IMM, Code 44).
Demonstrate adherence to CHRISTUS CORE values.
Identify, evaluate, and provide utilization review services, analyzing information supplied by physicians to make timely review determinations.
Take appropriate follow‑up action when utilization criteria are not met.
Proactively refer cases for medical necessity reviews, peer‑to‑peer reviews, and denial avoidance.
Collaborate with the Physician Advisor for secondary reviews.
Review patient status at admission to determine medical necessity of hospitalization and appropriate level of care or placement.
Review surgery schedules to ensure proper ordering and authorization of planned surgeries.
Review Observation status patients to determine acceptable discharge or conversion to inpatient status.
Identify and resolve issues regarding clinical appropriateness, coverage, and payor denials.
Maintain consistent communication with payors to coordinate certification of hospital services.
Coordinate and facilitate patient care progression throughout the continuum and document medical necessity at each level of care.
Evaluate care by the interdisciplinary team and advocate for standards of practice.
Analyze assessment data to identify potential problems and formulate care goals/outcomes.
Follow CHRISTUS HIPAA guidelines to protect PHI.
Attend scheduled department and interdepartmental meetings.
Demonstrate technology literacy across multiple systems.
Act as a catalyst for organizational change, responding with flexibility and teamwork.
Translate strategies into action steps; monitor progress; achieve results.
Demonstrate confidence, drive, and the ability to overcome challenges to achieve organizational goals.
Perform responsibilities in a manner that meets the specific needs of patients served.
Negotiate effectively with physicians, nursing staff, administrators, discharge planners, and payors.
Maintain strong verbal and written communication skills and knowledge of clinical protocols.
Adapt to frequently changing workloads and interruptions.
Work overtime or take calls as needed.
Travel to other facilities as required.
Participate in Multidisciplinary/Patient Care Progression Rounds.
Escalate cases per policy to Physician Advisors and/or CM Director.
Document in the medical record per regulatory and departmental guidelines.
Assist with special projects as requested.
Serve as a preceptor or orienter to new associates.
Assume responsibility for professional growth and development.
Familiarity with InterQual and MCG preferred.
Demonstrate excellent verbal and written communication for diverse populations.
Apply critical and analytical thinking skills.
Exhibit clinical competency.
Multitask and function in a stressful, fast‑paced environment.
Maintain knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
Understand pre‑acute and post‑acute levels of care and community resources.
Work independently and exercise sound judgment when interacting with physicians, payors, patients, and families.
Understand internal and external resources and community options.
Perform other duties as assigned.
Requirements & Qualifications
Graduated from an accredited School of Nursing or have at least five years of successful experience as a Utilization Management Nurse I at CHRISTUS Health.
At least two years of clinical experience, with at least one year in an acute care setting, or have proven success as a Utilization Management Nurse I at CHRISTUS Health.
RN license in the state of employment or a valid compact; LPN or LVN license accepted for associates with five or more years of demonstrated success in the UM Nurse I role.
Certification in Case Management preferred; BLS preferred.
Work Hours 8:00 AM – 5:00 PM, Monday‑Friday
Employment Type Full‑time
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