Sr Utiliz. Review Spclst Nurse

At Houston Methodist, the Sr Utilization Review Specialist Nurse (URSN) position is a licensed registered nurse (RN) responsible for promoting the achievement of optimal clinical and resource outcomes, accountable for a designated assignment that is considered more complex and resource intensive. This position has achieved an expert level at all objectives delineated in the Utilization Review Nurse and Utilization Review Specialist Nurse job roles and is responsible for facilitating appropriate length of stay (LOS) and reimbursement for all hospital admissions in accordance with set goals and objectives. The Sr URSN position assures that admission and continued stay are medically necessary, communicating clinical information to payers to ensure reimbursement. This position analyzes variances to identify opportunities for improvement and acts as the key information and education resource for the interprofessional health care team. The Sr URSN position promotes and maintains compassionate quality of care through collaboration with all service team members and works with the leadership team for special project activities related but not limited to, throughput, utilization review and utilization management to align with the visions and goals of the department and organization. This position will lead projects or perform specialized responsibilities as a regular part of their normal job responsibilities.

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 Case Managment certification: ACHPN-HPCC or CCM or CMC or ACM-NBCM or CDCES or CHPN-HPCC or CMGT-BC or CM-ABOHN or CMCN or ANCC-NCM

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

• Ability to effectively communicate with physicians, colleagues, and payer representatives in a manner consistent with a customer service focus and application of positive language principles

• Knowledge of Medicare, Medicaid, and Managed Care requirements

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

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

• Skill-specific areas include regulatory requirements, pathway development/ implementation, ethics/healthcare law, etc.

• 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 as evidenced by capacity to prioritize multiple tasks and role components

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

• Expert knowledge of 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)

• Required passage of Interrater Reliability test (IRR)

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 Hospital is recognized by U.S. News & World Report as the No. 1 hospital in Texas and one of America’s “Best Hospitals.” As a full-service, acute-care hospital located in the Texas Medical Center and the flagship hospital of Houston Methodist, it has evolved into one of the nation’s largest nonprofit teaching hospitals and a leader in innovative medical research with a comprehensive residency program. Two of Houston Methodist’s primary academic affiliates are among the nation’s leading health care organizations: Weill Cornell Medicine and New York-Presbyterian Hospital. Houston Methodist also has affiliations with Texas A&M University and the University of Houston. With 948 operating beds, 85 operating rooms and more than 8,400 employees, Houston Methodist Hospital offers unparalleled care for thousands of patients from around the world.

Houston Methodist is an Equal Opportunity Employer.