REQUIRED EDUCATION / EXPERIENCE:
Graduation from an accredited school of professional nursing and current Texas Nursing licensure as a professional registered nurse. Minimum of three years of full time wage earning experience as a professional nurse in a health care setting.
Performs technical and administrative work required to evaluate the necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities. Supports the UTMB Utilization Management Program utilizing clinical knowledge, expertise, and criteria guidelines.
Commensurate with experience.
The pay band for this position is NS22.
Specific Job Related Duties
In this role, you will perform technical and administrative work required to evaluate the necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities. Supports the UTMB Utilization Management Program utilizing clinical knowledge, expertise, and criteria guidelines. Helping to improve clinical decision-making and care management across the medical and behavioral health continuums of care.
The primary responsibility of the utilization review nurse is to review medical records and prepare clinical appeals (when appropriate) on medical necessity, level of care, length of stay, and authorization denials for hospitalized patients. An understanding of the severity of an array illnesses, intensity of service, and care coordination needs are key, as the nurse must integrate clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the hospitalized patient. The utilization review nurse works with the multidisciplinary team to assess and improve the denial management, documentation, and appeals process of such findings.
The utilization review nurse manages all activities related to the monitoring, interpreting, and appealing of clinical denials received from third-party payers and ensures accuracy in patient billing. The position is integral to the organization, as successful appeals by the nurse result in the overturning of denied claims and recovered revenue for the health care provider. Those in the position also work in collaboration with physician advisers to support policy development, process improvement, and staff education related to clinical denial mitigation.
RN with BSN or higher, certification in Case Management preferred.
Our Ideal Candidate will have:
- Experience with Interqual and/or MCG
- Knowledge of Medicare/Medicaid guidelines
- Advanced communication skills:
- Ancillary departments
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Equal Employment Opportunity
UTMB Health strives to provide equal opportunity employment without regard to race, color, national origin, sex, age, religion, disability, sexual orientation, gender identity or expression, genetic information or veteran status. As a VEVRAA Federal Contractor, UTMB Health takes affirmative action to hire and advance women, minorities, protected veterans and individuals with disabilities.
Req id: 65319 Apply