Job Description

To monitor adherence to the hospital’s utilization review plan to ensure the effective and efficient use of hospital services. Responsible for ensuring the appropriateness of hospital admissions and extended hospital stays. An understanding of the severity of an array of illnesses, intensity of service, and care coordination needs are the key, as the nurse must integrate clinical knowledge with billing knowledge to review, evaluate and arrange peer to peers when clinical denials related to medical necessity of the patient while hospitalized. UM nurse will work closely in collaboration with physician advisers to support policy development, and process improvement.

Work Experience:

• Two (2) years prior experience with Utilization Management.
• Previous training and demonstrated competence in negotiations, quality assurance, case management outcomes, and keyboarding/computer use.
• Experience with InterQual and/or Milliman Care Guidelines. Strong organizational and time management skills.
• Ability to work on extremely complex problems where analysis of situation or data requires an evaluation of intangible variance factors.

License/Registration/Certification:

• Current RN License to practice in the State of Texas.

Education and Training:

• Associate’s Degree in Nursing, BSN preferred.

Skills:

• Ability to utilize proficient verbal, written and interpersonal communication skills.
• Ability to work on extremely complete problems where analysis of situations or data requires an evaluation of intangible variance factors.
• Knowledge of managed care, reimbursement and utilization management.
• Knowledge of current International Classification of Disease (ICD-10), Diagnostic Related Groups (DRGs), and medical necessity criteria.
• Knowledge of claims denials and appeals processing
• Ability to coordinate and manage multiple priorities, projects simultaneously, reprioritizing as necessary
• Ability to self-motivate, multi-task and prioritize in a fast paced environment.
• Ability to use analytical and problem solving skills.
• Knowledge of HIPAA standards.
• Knowledge of various insurance plan coverages for Home Health, DME, SNF, LTAC agencies.
• Works well with people of all social, economic, and cultural backgrounds.
• Strong customer service orientation.
• Knowledgeable regarding community resources.
• Knowledge of basic computer, word-processing, and spreadsheet skills, Microsoft.
• Ability to operate standard office equipment.
• Knowledge of English grammar, punctuation and spelling.

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