Utilization Review Specialist Nurse

At Houston Methodist, the Utilization Review Specialist Nurse (URSN) 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. In addition to performing the duties of the URN, this position is able to cover a multitude of utilization review functions through point of entry, observation progression of care management, concurrent review and denials reviews. Additionally, the URSN will 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 URSN 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. The URSN position helps drive change by identifying areas where performance improvement is needed (e.g., day-to-day workflow, education, process improvements).

Requirements:

Qualifications:

LICENSES AND CERTIFICATIONS - REQUIRED

• RN - Registered Nurse - Texas State Licensure -- Compact Licensure - Must obtain permanent Texas license within 60 days (if establishing Texas residency) AND
• Magnet - ANCC Recognized Certification (ANCC) -- in Case Management OR
• ACM - Accredited Case Manager (NBCM)

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

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

• Comprehensive knowledge of Medicare, Medicaid, and Managed Care requirements

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

• Comprehensive 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)

• Competent computer skills of the entire Microsoft Office Suite (Access, Excel, Outlook, PowerPoint, and Word

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 The Woodlands Hospital opened in June 2017 as the eighth hospital in the Houston Methodist system. This 267-bed, 725,000-square-foot, full-service, acute-care hospital offers many of the same services as our flagship hospital in the Texas Medical Center. Also, on the beautiful hospital campus, located at the intersection of Interstate 45 and Texas State Highway 242, are two medical office buildings, which include a Breast Care Center; Cancer Center; infusion center; heart and vascular services; neurology; orthopedics and sports medicine; rehabilitation services; wellness services; an outpatient laboratory; and several other multispecialty physician practices. In January 2022, Houston Methodist The Woodlands opened Healing Tower — a $250 million expansion project that added 106 beds, focused on medical-surgical and women’s services, and provided nine operating rooms. The project also included the expansion of the endoscopy center, emergency department and diagnostic imaging department with an enhanced neurodiagnostic and interventional center.

Houston Methodist is an Equal Opportunity Employer.