Utilization Review Nurse

At Houston Methodist, the Utilization Review Nurse (URN) position is a licensed registered nurse (RN) who comprehensively conducts point of entry and concurrent medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, payer guidelines, CMS, and other state agencies. This position prospectively or concurrently determines the appropriateness of inpatient or observation services following review of relevant medical documentation, medical guidelines, and insurance benefits and communicates information to payers in accordance with contractual obligations. The URN position serves as a resource to the physicians and provides education and information on resource utilization and national and local coverage determinations (LCDs & NCDs). This position collaborates with case management in the development and implementation of the plan of care and ensures prompt notification of any denials to the appropriate case manager, denials, and pre-bill team members, as well as management.

Requirements:

Qualifications:

LICENSES AND CERTIFICATIONS - REQUIRED

• RN - Registered Nurse - Texas State Licensure and/or Compact State Licensure within 60 days OR
• RN-Temp - Registered Nurse - Temporary State Licensure within 60 days

KNOWLEDGE, SKILLS, AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations

• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security

• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles

• Progressive knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and knowledge of local and national coverage determinations

• Recent work experience in a hospital or insurance company providing utilization review services

• Knowledge of Medicare, Medicaid, and Managed Care requirements

• Progressive knowledge of community resources, health care financial and payer requirements/issues, and eligibility for state, local, and federal programs

• Progressive knowledge of utilization management, case management, performance improvement, and managed care reimbursement

• Ability to work independently and exercise sound judgment in interactions with physicians, payers, and health care team members

• Strong assessment, organizational, and problem-solving skills

• Maintains level of professional contributions as defined in Career Path program

• Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44)

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below.

• On Call* Yes

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area No

Company Profile:

Houston Methodist West Hospital is committed to leading medicine in West Houston, Katy and surrounding communities by delivering the Houston Methodist standard of exceptional safety, quality, service and innovation. The growing campus offers 253 beds and access to the most innovative medical and surgical care available, including cardiology and cardiovascular surgery; neurology and neurosurgery; comprehensive cancer care; orthopedics and sports medicine; gastroenterology; bariatrics; childbirth center with level III NICU; emergency care; and advanced imaging.

Houston Methodist is an Equal Opportunity Employer.