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Utilization Manager Reviewer Registered Nurse - SWHR CIN - Sunday - Thursday - Fort Worth

Company: Texas Health Resources
Location: Fort Worth
Posted on: September 13, 2020

Job Description:

Southwestern Health Resources is seeking to hire a Utilization Manager Reviewer Registered Nurse to support our Southwestern Health Resources Utilization Management Department.The address is 900 Jerome Street, Fort Worth Texas, 76104Salary range is $33.57/hour - Max 49.40/hour - based on relevant experience.Work Schedule* Full-time: 40 hours per week, Sunday - Thursday, 10am-7pmThe UM Reviewer RN is accountable for performing initial, concurrent, or post service review activities; discharge care coordination; and assisting with efficiency and quality assurance of medical necessity reviews in alignment with Federal, State, Plan, and Accreditation standards. The UM reviewer serves as a liaison between providers/ facilities and Care Management Division. The essential job duties for this position are:* Supports the Collaborative Care Management Model as a working partner with physicians, social workers, pharmacists and other professional staff.* Accurately applies decision support criteria* Demonstrates proficiency with caseload assignment and ability to manage complex cases effectively.* Demonstrates an understanding of funding resources, services and clinical standards and outcomes.* Demonstrates knowledge of case management standards of practice and processes including identification and assessment, planning, interventions and evaluation.* Demonstrates a solid understanding of managed care trends, Medicare, and Medicaid regulations, reimbursement and the effect on utilization and outcomes of the different methods of reimbursement.* Demonstrates the ability to develop departmental interfaces with internal and external customers to provide exemplary service and achieve goals.* Demonstrates participation in multi-disciplinary team rounds if designated to cover a facility designed to addressutilization/resource and progression of care issues. Assists in developing and implement an improvement plan to address issues.* Implement discharge plan to prevent avoidable days or delays in discharge.* Transition patient to next level of care in coordination with facility Discharge Planner.* Identify and refer complex risk members to case management.* Complete documentation timely, completely, and accurately in accordance with: (a) eligibility and benefits (b) clinical guidelines/criteria (c) legal and regulatory requirements.* Identify documents and refer cases to the UM Team Leader for medical review when services do not meet medical necessity criteria, and/or appropriate level of care, and/or potential quality issues.* Perform other duties as assigned.QualificationsThe ideal candidate will possess the following qualifications:* Associate's Degree Nursing required Or* Bachelor's Degree Nursing preferred* Master's Degree Nursing preferred* 3 Years Utilization management experience in an acute or post-acute provider, health plan or other care company experience required and* 2 Years experience in direct patient care as an RN, preferred acute care (ER, ICU, or Medical/ Surgical) required and* 5 Years experience in Health Plan Utilization Review, Discharge Planning and Medical Case Management preferred.* 2 years expereince recent Medicaid Advantage experience highly preferred.* Registered Nurse license upon hire requiredSkills* Experience and knowledge of Milliman Guidelines or similar clinical guidelines preferred* Strong analytical and organizational skills* Working knowledge and ability to apply professional standards of practice in work environment.* Knowledge of specific regulatory, managed care requirements, and strong attention to detail.* Working knowledge of computers and basic software applications used in job functions such as word processing, graphics, databases, spreadsheets, etcSouthwestern Health Resources Clinically Integrated Network (SWHR CIN) is a partner company of Texas Health. If hired for this position, you will become a SWHR CIN employee rather than a Texas Health employee.

Keywords: Texas Health Resources, Fort Worth , Utilization Manager Reviewer Registered Nurse - SWHR CIN - Sunday - Thursday - Fort Worth, Healthcare , Fort Worth, Texas

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