Utilization Management Nurse III
Company: Christus Health
Location: San Antonio
Posted on: September 28, 2024
Job Description:
Utilization Management Nurse III role requires determining
clinical appropriateness of care and ensuring proper hospital
resource utilization.
CHRISTUS Santa Rosa Hospital - Westover Hills is a 150-bed hospital
serving the fastest growing area of San Antonio, providing
specialized care in orthopedic and surgical services, ICU, women's
services, and more.
Responsibilities:
- Meet expectations of OneCHRISTUS Competencies: Leader of Self,
Leader of Others, or Leader of Leaders.
- Apply clinical competency and judgment to perform comprehensive
assessments and determine medical necessity.
- Assess patient population for medical necessity, level of care,
and appropriateness of setting and services.
- Utilize MCG/InterQual Care Guidelines and/or health
system-approved tools to track impact and variance.
- Coordinate and facilitate correct identification of patient
status.
- Analyze quality and comprehensiveness of documentation and
collaborate with physician and treatment team.
- Facilitate joint decision-making with interdisciplinary team
regarding patient status and outcomes.
- Demonstrate knowledge of regulatory requirements and ensure
compliance.
- Adhere to CORE values of CHRISTUS.
- Utilize independent scope of practice to identify, evaluate,
and provide utilization review services.
- Take follow-up action when established criteria for utilization
of services are not met.
- Proactively refer cases to physician advisor for medical
necessity reviews and denial avoidance.
- Effectively collaborate with interdisciplinary team, including
physician advisor for secondary reviews.
- Proactively review patients at point of entry to determine
medical necessity and appropriate level of care.
- Review surgery schedule to ensure planned surgeries are ordered
in appropriate status and necessary authorization has been
obtained.
- Regularly review patients in Observation status to determine if
patient is appropriate for discharge or conversion to inpatient
status.
- Proactively identify and resolve issues regarding clinical
appropriateness recommendations, coverage, and potential or actual
payor denials.
- Maintain consistent communication and exchange of information
with payors to coordinate certification of hospital
services.
- Coordinate and facilitate patient care progression throughout
continuum and communicate and document to support medical
necessity.
- Evaluate care administered by interdisciplinary health care
team and advocate for standards of practice.
- Analyze assessment data to identify potential problems and
formulate goals/outcomes.
- Follow CHRISTUS Guidelines related to Health Insurance
Portability and Accountability ACT (HIPPA) to prevent or detect
unauthorized disclosure of Protected Health Information
(PHI).
- Attend scheduled department staff meetings and/or
interdepartmental meetings as appropriate.
- Possess and demonstrate technology literacy and ability to work
in multiple technology systems.
- Act as catalyst for change in organization; respond to change
with flexibility and adaptability.
- Translate strategies into action steps; monitor progress and
achieve results.
- Demonstrate confidence, drive, and ability to face and overcome
challenges and obstacles to achieve organizational goals.
- Demonstrate competence to perform assigned responsibilities in
a manner that meets population-specific and developmental needs of
patients served by department.
- Possess negotiating skills that support ability to interact
with physicians, nursing staff, administrative staff, discharge
planners, and payers.
- Excellent verbal and written communication skills, knowledge of
clinical protocol, normative data, and health benefit
plans.
- Must adjust to frequently changing workloads and frequent
interruptions.
- May be asked to work overtime or take calls.
- May be asked to travel to other facilities to assist as
needed.
- Actively participates in Multidisciplinary/Patient Care
Progression Rounds.
- Escalates cases as appropriate and per policy to Physician
Advisors and/or CM Director.
- Documents in medical record per regulatory and department
guidelines.
- May be asked to assist with special projects.
- May serve as preceptor or orienter to new associates.
- Assumes responsibility for professional growth and
development.
- Must have familiarity with criteria sets including InterQual
and MCG preferred.
- Must have excellent verbal and written communication.
- Must have critical and analytical thinking skills.
- Must have demonstrated clinical competency.
Requirements:
- BSN required or demonstrated success as a Registered Nurse in
the Utilization Management Nurse II role for at least five years at
CHRISTUS Health.
- Demonstrated leadership skills - formal or informal.
- Demonstrated willingness to mentor team members including
onboarding and orienting new associates.
- Demonstrated problem-solving skills.
- Demonstrated positive approach in difficult and challenging
situations.
- Demonstrated agent for change and change management.
Education/Skills:
- BSN required or demonstrated success as a Registered Nurse in
the Utilization Management Nurse II role for at least five years at
CHRISTUS Health.
- Demonstrated leadership skills - formal or informal.
- Demonstrated willingness to mentor team members including
onboarding and orienting new associates.
- Demonstrated problem-solving skills.
- Demonstrated positive approach in difficult and challenging
situations.
- Demonstrated agent for change and change management.
Experience:
- 5 years of experience in the clinical setting with at least 3
years in the acute care setting required.
Licenses, Registrations, or Certifications:
- RN License in state of employment or compact required.
- Certification in Case Management preferred.
- BLS preferred.
Work Schedule: Varies
Work Type: Part Time
Keywords: Christus Health, San Antonio , Utilization Management Nurse III, Executive , San Antonio, Texas
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