Job Description

Texas Health Resources is seeking to hire a Clinical Review Utilization Manager Registered Nurse for our Clinical Review Department.

Employees will have the opportunity to work from home after completion of training. Must live in the North Texas, DFW area. Orientation will be held at the Chase Building – 500 East Border Street, Arlington, Texas 76010.

Salary range is $35.48/hour – Max $49.18/hour – based on relevant experience.

• Full Time – 7am-3:30pm 5 days a week some weekends.

The Clinical Review Utilization Manager is responsible for determining initial admission status and level of care recommendations for inpatient admissions, observation and outpatient admissions for any hospital in the THR system. The essential job functions for this position are:

• Conduct initial admission review of inpatient, observation and outpatient admissions (commercial insurance, Medicare Advantage and self-pay) according to established criteria set adopted by System. Conduct initial admission review of inpatient, observation and outpatient admissions with traditional Medicare for compliance with the New IPPS rule.

• Provide clinical information to payors as needed for completion of pre-certification process.

• Ensure proper authorization requirements are met with each admission. Obtains or ensures acquisition of appropriate precertification's/ authorizations from third party payers and placement to appropriate level of care prior to hospitalization or upon admission utilizing medical necessity criteria and third party payer guidelines.

• Obtains, or facilitates, acquisition of urgent/emergent authorizations, continued stay authorizations, as needed and with compliance with all regulatory and contractual requirements.

• Maintains a working knowledge of care management, utilization review changes, authorization changes, contract changes, regulatory requirements, etc.

• Adheres to the policies, procedures, rules, regulations, and laws of the hospital and federal and state regulatory bodies.

• Communicates and collaborates with the CBO and medical records to render appropriate information needed to secure reimbursement.

• Provide consultation to medical and nursing staff, health information management, and payors on potential issues with reimbursement of hospitalization.

• Evaluate concurrent potential denials or payment issues and initiate communication with admitting physician to assure proper documentation for selected admission status.

• Collaborates and communicates with payor via phone, fax or computer system per payor contract.

• Initiates and facilitates physician communications relative to the UR process when indicated. Assists and facilitates the physician peer-to-peer review process with insurance medical directors as indicated.

• Communicates payer issues and medical necessity concerns with members of the health care team.

• Escalate incorrect status concerns to UM manager.

• Determines working DRG with each initial review via Canopy, or other Care Management tool. Discusses working DRG issues as needed with Care Transition Manager.

• Performs other duties as assigned.

The ideal candidate will possess the following 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 And

• 1 year Utilization Management required.

• Experience in case management, and/or the application of medical necessity criteria preferred

• Milliman Care Guidelines preferred

• Registered Nurse License to practice professional nursing in the state Texas required.

• Specialty certification preferred.

• Requires interpersonal, analytic, and critical thinking skills for problem solving and decision making.

• Broad and intimate knowledge of reimbursement and regulatory requirements.

• Decisive judgment and the ability to work with minimal supervision.

• Must be able to work in a fast-paced environment requiring adaptability, flexibility, and independence while

demonstrating high professional standard, leadership, and team membership skills.

• Must be well organized and have the ability to prioritize and handle multiple tasks efficiently and independently.

• Have demonstrated ability to initiate and follow through with multiple projects.

• Proficient computer skills with experience in: MS Office, internet navigation, clinically-based software, and financially-based software.

Texas Health Resources is one of the largest faith-based, nonprofit health care delivery systems in the United States and the largest in North Texas in terms of patients served. Texas Health has 25 acute-care and short-stay hospitals that are owned, operated, joint-ventured or affiliated with the system. It has more than 3,800 licensed beds, more than 21,100 employees of fully-owned/operated facilities plus 1,400 employees of consolidated joint ventures, and counts more than 5,500 physicians with active staff privileges at its hospitals.

At Texas Health, we strive to create an atmosphere of respect, integrity, compassion and excellence for all who come in contact with us, be they patients or our employees. We are committed to diversity in our workforce, and our mission to serve spreads across ethnic, cultural, economic and generational boundaries. We invite you to join us in furthering your career and our accomplishments and philosophy of excellence.

• 2019 FORTUNE Magazine's "100 Best Companies to Work For®” (5^th year in a row)

• 2019 Becker's Healthcare "150 Great Places to Work in Healthcare" (5^th year in a row)