Job Summary

The Utilization Management Review Nurse (UMRN) performs technical and administrative work required to evaluate the necessity, appropriateness, and efficiency of the utilization of medical services procedures and facilities. This role supports the health system by utilizing clinical knowledge, expertise and industry standard clinical guidelines carrying the responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. The UMRN promotes 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 to deliver the best holistic outcomes for all patients. This position will 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 physician and/or other members of the healthcare team.

The UMRN participates in quality improvement activities, exemplifies professionalism, and promotes 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
- Other: 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.