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Role Description

This role involves utilization management and clinical review for inpatient admissions, observation, and outpatient admissions.

• Responsible for determining initial admission status and level of care recommendations for inpatient admissions, observation, and outpatient admissions.
• Conduct initial admission review of inpatient, observation, and outpatient admissions according to established criteria.
• Provide clinical information to payors for completion of the pre-certification process.
• Ensure proper authorization requirements are met with each admission.
• Obtain or facilitate acquisition of urgent/emergent authorizations and continued stay authorizations.
• Maintain a working knowledge of care management, utilization review changes, and regulatory requirements.
• Provide consultation to medical and nursing staff, health information management, and payers on reimbursement issues.
• Partner with hospital care transitions managers to assure effective hand-off of information related to the plan of care.
• Work with bedside nurses and care team members to assure orders related to status are accurate and valid.
• Evaluate concurrent potential denials or payment issues and initiate communication with admitting physician.
• Initiate and facilitate physician communication relative to the UR process when indicated.
• Determine working DRG with each initial review via CareConnect1 or other Utilization Management tool.
• Cover multiple THR sites adjusting practice to meet the requirements of each location.

Qualifications

• Associate's degree in Nursing required
• Bachelor's degree in Nursing preferred
• 5 years inpatient clinical nursing experience in an acute hospital setting required
• 1 Year Utilization Management experience preferred
• Case management and/or the application of medical necessity criteria preferred
• Texas RN upon hire required
• Case management certification within 12 months of hire preferred
• MCG certification within 12 months of hire preferred

Requirements

• Must be available to train for 4-6 weeks during the week then transition to weekends
• PRN Weekends from 6:45a - 3:15p with some holiday requirements

Benefits

• Benefits include 401k, PTO, medical, dental, Paid Parental Leave, flex spending, tuition reimbursement, Student Loan Repayment Program, and several other benefits.
• A supportive, team environment with outstanding opportunities for growth.