PRN Utilization Management Review Nurse

Harris Health System is the public healthcare safety-net provider established in 1966 to serve the residents of Harris County Texas. As an essential healthcare system Harris Health champions better health for the entire 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 Healths robust network of 39 clinics health centers specialty locations and virtual telemedicine technology. Harris Health is among an elite list of health systems in the U.S. achieving Magnet® nursing excellence designation for its hospitals the prestigious National Committee for Quality Assurance designation for its patient-centered clinics and health centers and its strong partnership with nationally recognized physician faculty residents and researchers from Baylor College of Medicine McGovern Medical School at The University of Texas Health Science Center at Houston UTHealth The University of Texas MD Anderson Cancer Center.

Job Summary

The Utilization Management Review Nurse (UMRN) performs technical and administrative work required to evaluate the necessity appropriateness and efficiency of the utilization of medical services procedures and facilities. This role supports the health system by utilizing clinical knowledge expertise and industry standard clinical guidelines carrying the responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity.

Responsibilities

• Promotes quality care and cost-effective outcomes to enhance the physical psychosocial and vocational health of individuals
• Partners with Care Management Physician Advisors Finance and 3rd party payers to deliver the best holistic outcomes for all patients
• Works with payers to reconcile denials and reconsiderations assist with appeals as needed and arrange peer to peer level review
• Collects analyzes and addresses variances from the plan of care/care path with physician and/or other members of the healthcare team

Minimum Qualifications

• Degrees: 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 or Red Cross approved program)
• Work Experience:
• 5 Years of Experience
• Strong clinical background in a variety of acute healthcare settings including 2 years in Case Management Quality Management Utilization Management or Coding
• Communication Skills:
• 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

Job Attributes

• Knowledge: Analytical, Mathematics, Medical Terms, Other Utilization review tools (MCG and/or Change healthcare Interqual)
• Work Schedule: Flexible 8 hour shifts as per system need variable to 10-12 as needed
• Weekends: Depends on needs of system
• Telecommute: Yes
• Holidays: Depends on needs of system

Other Special Requirements

• Equipment Operated: Standard office equipment, computer software, etc.