Harris Health System is the public healthcare safety-net provider established in 1966 to serve the residents of Harris County, Texas. Harris Health champions better health for the community, with a focus on low-income uninsured and underinsured patients, through acute and primary care, wellness, disease management and population health services. Ben Taub Hospital (Level 1 Trauma Center) and Lyndon B. Johnson Hospital (Level 3 Trauma Center) anchor Harris Health's network of clinics and virtual technology. Harris Health is one of a few systems designated Magnet(r) for nursing excellence and partners with leading medical schools and centers.
The Utilization Management Review Nurse (UMRN) performs technical and administrative work to evaluate the necessity, appropriateness, and efficiency of utilization of medical services, procedures and facilities. This role ensures care at the appropriate level based on medical necessity and promotes quality care and cost-effective outcomes. The UMRN collaborates with Care Management, Physician Advisors, Finance, and 3rd party payers to achieve holistic outcomes for patients. This position coordinates with payers to reconcile denials and reconsiderations, assists with appeals as needed, and arranges peer-to-peer reviews while collecting and analyzing variances from the plan of care with the physician and/or other members of the healthcare team.
The UMRN participates in quality improvement activities and promotes a customer-friendly environment by using ServiceFIRST behaviors in interactions with Harris Health team members, payer vendors, and physicians.
Responsibilities
Evaluate the necessity, appropriateness, and efficiency of utilization of medical services, procedures and facilities.
Collaborate with Care Management, Physician Advisors, Finance, and 3rd party payers to ensure care at the appropriate level based on medical necessity.
Work with payers to reconcile denials and reconsiderations; assist with appeals as needed; arrange peer-to-peer level review.
Collect, analyze, and address variances from the plan of care/care path with the physician and/or other members of the healthcare team.
Participate in quality improvement activities and promote ServiceFIRST behaviors in interactions with stakeholders.
Qualifications
Education : Graduated from an accredited school of Nursing with a Bachelors in Nursing.
Licenses & Certifications :
Registered Nurse: Licensed to practice nursing in the State of Texas.
Case Management Certification (ACM or CCM) within two years of hire.
Basic Life Support: American Heart Association (AHA) or Red Cross approved program.
Experience :
5 Years of Experience with a strong clinical background in acute healthcare settings, including 2 years in Case Management, Quality Management, Utilization Management, or Coding.
Communication :
Above Average Verbal Communication (Heavy Public Contact)
Exceptional Verbal (Public Speaking)
Writing/Correspondence
Writing/Reports
Language : Bilingual Skills (Preferred)
Proficiencies :
MS Word
PC
MS Excel
MS PowerPoint
Knowledge, Skills & Abilities
Analytical
Mathematics
Medical Terms
Utilization review tools: MCG or Change Healthcare (InterQual)
Work Schedule
Flexible: 8 hour shifts as per system need; variable to 10-12 hours as needed.
Weekends: Depends on needs of system.
Telecommute
Holidays: Depends on needs of system.
Other Special Requirements
Equipment Operated: Standard office equipment, computer software, etc.