Acute Care, Analysis Skills, Basic Life Support (BLS), Cancer, Case Management, Certified Case Manager (CCM), Clinical Practices/Protocols, Communication Skills, Community Health, Computer Software, Disease Prevention and Control, Finance, Health Science, Healthcare, Hospital, Industry Standards, Mathematics, Medical Terminology, Medical Treatment, Medicine, Microsoft Excel, Microsoft PowerPoint, Microsoft Word, National Committee for Quality Assurance (NCQA), Nursing, Nursing Credentials, Office Equipment, Patient Care Denials, Presentation/Verbal Skills, Primary Care, Public Health, Public Safety, Quality Management, Quality of Care, Registered Nurse (RN), Reporting Skills, Telemedicine, Third-Party Payer, Treatment Plan, Utilization Management, Work From Home, Writing Skills
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 Health's 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; and the Tilman J. Fertitta Family College of Medicine at the University of Houston.
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. The UMRN promotes quality care and cost-effective outcomes to enhance the physical, psychosocial and vocational health of individuals, partnering with Care Management, Physician Advisors, Finance, and 3rd party payers to deliver the best holistic outcomes for all patients. This position will work with payers to reconcile denials and reconsiderations, assist with appeals as needed and arrange peer to peer level review while collecting, analyzing and addressing variances from the plan of care/care path with physician and/or other members of the healthcare team.
The UMRN participates in quality improvement activities, exemplifies professionalism, and promotes a customer-friendly environment by utilizing ServiceFIRST behaviors in interactions with Harris Health team members, payer vendors, and physicians.
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 (AHA) 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/Skills/Abilities:
- 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
- Holidays: Depends on needs of system.
Other Special Requirements
Equipment Operated: Standard office equipment, computer software, etc.
Apply
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Harris Health System
Harris Health is a nationally recognized health system comprising three teaching hospitals and an extensive network of ambulatory care centers serving the people of Harris County, Texas, since 1966. Staffed by the faculty, fellows and residents from two nationally ranked medical schools, Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth), Harris Health is the first healthcare system in Houston to receive the prestigious National Committee for Quality Assurance (NCQA) designation for its network of patient-centered medical homes.
Each year, Harris Health provides more than 1.8 million total outpatient visits through its more than 40 ambulatory care facilities. Additionally, Harris Health sees more than 177,000 emergency visits at its Level 1 and Level 3 trauma centers and 35,000 hospital admissions through its three hospitals: Ben Taub, LBJ and Quentin Mease. Established by voter referendum to enhance the level of charity care available in the community, Harris Health System has often received national recognition for serving those in need and for its achievements in operational excellence, such as being named to the 2011, 2012, 2013 and 2014 Most Wired Hospitals lists by the American Hospital Association's Hospitals & Health Networks magazine.
Additionally, Harris Health System is pleased that each of its three hospitals: Ben Taub, Lyndon B. Johnson and Quentin Mease - achieved Pathway to Excellence designation by the American Nurses Credentialing Center.
5,000 to 9,999 employees
https://www.harrishealth.org/en/pages/home.aspx