RN Utilization Management - FT Days at AdventHealth

Date Posted: 1/4/2022

Media

Job Snapshot

  • Job Schedule
    Full-Time
  • Location:
    Burleson, TX
  • Date Posted:
    1/4/2022
  • Job ID:
    22000192
  • Job Family
    Case Management
  • Shift
    1 - Day

Job Description


Description

Utilization Management Review Registered Nurse - Texas Health Huguley- operated as joint venture between Texas Health Resources and AdventHealth

Location Address: 11801 South Fwy., Burleson, TX  76028

Top Reasons to Work At Texas Health Huguley, Burleson, TX

  • Our care for patients extend to the spiritual level by praying with patients and families and providing on call, 24 hours, 7 days a week Chaplains for spiritual support.
  • Award winning facility and departments including “Great Place to Work” by Becker’s Hospital Review and Gallup.
  • Work with the latest technology and top experts including “Daisy Award” recipients while on the way to Magnet status—2020.
  • Amazing medical benefits through Aetna plus an onsite full-service fitness center.
  • Growth opportunities designed for each employee.
  • Located about 10 minutes from downtown Fort Worth and near TCU in the award-winning school district, Burleson ISD which also provides a low-cost of living.  

Work Hours:

Full Time / Days

You Will Be Responsible For:

  • Monitors admissions and performs initial patient reviews within 24 hours of admission; and when warranted by length of stay, utilization review plan, and/or best practice guidelines, on a continuing basis.
  • Performs pre-admission status recommendation in Emergency Department or elective procedure settings as assigned, to communicate with providers status guidance based on available information.
  • Maintaining thorough knowledge of payer guidelines, familiarity with payer processes for initiating authorizations, and following through accordingly to prevent loss of reimbursement, including the management of concurrent and pre-bill denials.
  • Ensuring all benefits, authorization requirements, and collection notes are obtained and clearly documented on accounts in the pursuit of timely reimbursement within established timeframes to avoid denials.
  • Works collaboratively and maintains active communication with physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate management of claims.
  • Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
  • Collaborates with medical staff, nursing staff, payor, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting. Communicates with all parties (i.e., staff, physicians, payers, etc.) in a helpful and courteous manner while extending exemplary professionalism. Anticipates and responds to inquiries and needs in an assertive, yet courteous manner. Demonstrates positive interdepartmental communication and cooperation.
  • ​​​​​​​Interacts with physicians, physician office personnel, and/or case management departments on an as-needed basis to assure resolution of pending denials, which have been referred to the physician for peer-to-peer review with the Medical Director of the insurance carrier.
Qualifications

What You Will Need:

  • Current and valid license to practice as a Registered Nurse.
  • ADN or BSN required.
  • Minimum 3 years acute care clinical nursing experience required.
  • Minimum 2 years Utilization Management experience, or equivalent professional experience.

Job Summary:

The role of the Utilization Management (UM) Registered Nurse (RN) is to use clinical expertise by analyzing

patient records to determine legitimacy of hospital admission, treatment, and appropriate level of care.

The UM RN leverages the algorithmic logic of the XSOLIS Cortex platform, utilizing key clinical data

points to assist in status and level of care recommendations.  The UM RN is responsible to document

findings based on department and regulatory standards.  When screening criteria does not align with the

physician order or a status conflict is indicated, the UM nurse is responsible for escalation to the Physician

Advisor or designated leader for additional review as determined by department standards. Additionally,

the UM RN is responsible for denial avoidance strategies including concurrent payer communications to

resolve status disputes.


This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

VIEW ALL JOBS BY:
Location | Organization | Category | Job Function