Utilization Review Nurse

Memorial Hermann Health System
Published
February 19, 2021
Location
Houston, TX
Category
Job Type

Description

At Memorial Hermann, we're about creating exceptional experiences for both our patients and our employees. Our goal is to provide opportunities for our diverse employee population that develop and grow careers in a team-oriented environment focused on patient care.

Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.

Job Summary

The Utilization Review Nurse serves as a contact and resource person to Health Solutions' members to the utilization review (UR) of healthcare services. The UR Nurse will be responsible for complying with utilization review procedures in accordance with Texas UR Certification requirements, as well as carrying out day to day pre-authorization functions. The Utilization Review Nurse, will also be responsible for issuing pre-authorization approvals/denials, notifying providers/enrollees of denials verbally and in writing. They will also coordinate pended cases for a review determination with Health Solutions Medical Director, coordinate pre-authorization activities with affiliated health plans and interface with network physician office staff when benefit coverage or UR questions or issues arise. To support care management initiatives, the UR Nurse shall also identify enrollees in need of case/disease management services so that proactive interventions can occur.

Job Description

Minimum Qualifications

Education: Graduate of an accredited school of nursing (Associates of Nursing or Bachelor of Nursing)

License/Certifications: Current, unrestricted Texas licensure to practice as a Registered Nurse required, unrestricted Certification in Utilization Review/Utilization Management preferred

Experience / Knowledge / Skills:

  • Three (3) to five (5) years experience in a Managed Care environment performing pre-authorization, concurrent review or case management
  • Knowledgeable and compliant with all relevant laws, rules regulations and accreditation standards and requirement
  • Strong clinical background in nursing
  • Knowledge of insurance terminology
  • Basic knowledge of computer systems
  • Excellent verbal and written communication skills.
  • Ability to perform multiple tasks simultaneously, work under pressure, and meet critical deadlines
  • Excellent typing skills
  • Ability to perform ICD-9/CPT coding
  • Ability to work independently, manage time and prioritize projects
  • Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of "we advance health" through innovation, accountability, empowerment, collaboration, compassion and results while ensuring one Memorial Hermann.

Principal Accountabilities

  • The UR Nurse, will be responsible for carrying out the following duties and responsibilities.
  • Serves as a resource to the Claims Department in determining medical necessity of claim submitted by network physicians according to Health Solutions payor's prospective review criteria and authorization procedures.
  • Coordinates pre-certification activities with contracted health plans and interfaces with providers and/or enrollees when pre-certification issues arise.
  • Educates and affords training to network physicians/office staff on prospective review/pre-certification requirements.
  • Collects and/or documents all required enrollee clinical and co-morbidity information during the pre-authorization process to support care management initiatives and sound decision making for review determinations.
  • Utilizes InterQual, Milliman other Medical Management/health plan endorsed or developed criteria when evaluating cases for pre-authorization; considers special needs and other unique medical needs of enrollees as part of the evaluation process.
  • Provides direction and answers phone inquiries from providers and enrollees regarding Health Solutions' pre-authorization program.
  • Routes provider related UM complaints to the correct department for documentation and investigation when calls are received directly from providers or enrollees.
  • Conducts timely medical necessity reviews in accordance with TDI required time-lines.
  • Establishes/maintains good rapport with providers to obtain information necessary for review determinations.
  • Presents all cases that do not meet Clinical criteria, questionable admissions, and prolonged lengths of stays to the Medical Director for determination.
  • Collects accurate data for system input by using correct coding of diagnoses and/or procedures and utilize complete and concise documentation of all pertinent information obtained.
  • Assists the Director and Medical Director in identifying additional guidelines or protocols needing either development or refinement in order to support an efficient, effective and quality oriented pre-authorization process

Care Management Duties

  • Serves as a liaison with participating hospitals' Case Management staff in order to be apprised of inpatient admission status and care management needs; serves as a resource to the hospital staff by assisting in alternative of care placements in compliance to the applicable managed care plan or certified workers' compensation network benefit coverage requirements.
  • Identifies enrollees in need of case/disease management services and makes referrals to either the affiliated hospital Case Management staff and the Continuum of Care Coordinator for enrollees with multiple or co-morbid conditions discharged to the outpatient setting.
  • Follows other procedures to make appropriate referrals relative to individual cases (Case management, Stop Loss, etc.).
  • Educates providers and other physicians about the Health Solutions case management referral program as potential enrollees are identified via the pre-authorization process
  • Quality Improvement Duties
  • Identifies potential quality of care issues as relates to data collected as part of the pre-authorization process; flags cases for review by the Appeals & Outcomes Coordinator
  • Conducts medical research in order to assist the Medical Director and the Medical Management Manager/Director in the development of ambulatory treatment guidelines to support prospective review and/or the quality management program.
  • Reports potential risk management cases or situations to the Medical Management Manger/Director for immediate intervention or investigation.
  • Tracks enrollee cases for prospective QI study or as needed for reporting, as may be delegated by the Quality & Outcomes Coordinator.

Other Job Duties

  • Adheres to and apply all Health Solutions policies, procedures, and guideline appropriately.
  • Acts as mentor and lead less experienced Utilization Review staff.
  • Attends a minimum of two in-house in-services per year.
  • Processes and maintain confidential information according to confidentiality policy.
  • Performs other related duties as requested by Supervisor, Manager, or Director.
  • Achieves an in-depth knowledge of client benefit plans.
  • Maintains a 90% or greater score on the quarterly audit tool.
  • Communicate, collaborate and cooperate with internal and external stakeholders.
  • Adheres to all Compliance/Program Integrity requirements.
  • Complies with HIPAA Regulations
  • Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
  • Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
  • Other duties as assigned.
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