Utilization Review RN – PRN – Monday-Friday Days

Three (3) years of utilization review experience in acute care setting

WHY UT SOUTHWESTERN?
With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the number 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you’ll discover a culture of teamwork, professionalism, and a rewarding career!

JOB SUMMARY
Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations and documentation requirements.

BENEFITS
UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include:

• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100% coverage for preventive healthcare-no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer
• Learn more about these and other UTSW employee benefits!

EXPERIENCE AND EDUCATION
Required

• Education
  Graduate of accredited nursing program and holds an active unrestricted RN license in the State of Texas

• Experience
  5 years experience to include 2 years of clinical experience and minimum of 3 years of recent utilization review experience. and
  Prior experience with Epic CCM.

• Licenses and Certifications
  (RN) REGISTERED NURSE Holds an active unrestricted license in the State of Texas. and

Preferred

• Experience
  Acute care experience preferred

JOB DUTIES

• Collaborates with the access management team to provide accurate and complete clinical information in order to obtain authorization.
• Conducts inpatient admission review for Medicare and Medicaid beneficiaries as we1l as private insurance members and self-pay patients based on evidence-based guidelines.
• Admission reviews are done concurrently at the point of entry in collaboration with ED and admitting physician and the cooperation with the access management team to determine the appropriateness of hospital level of care.
• Confers with admitting physicians when documentation does not appear to support hospital level of care and offers suggestions for clarity and completeness.
• Uses InterQual Level of Care Criteria for appropriateness for inpatient level of care or observation services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two-midnight stay.
• Keeps current on all Federal, State and local regulatory changes that affect delivery or reimbursement of acute care services within the scope of Utilization Management. Uses knowledge of national and local coverage determinations to appropriately
  advise physicians.
• Proactively collaborates with admitting physician to provide coaching on accurate level of care determination at point- of-hospital entry.
• Consistently identifies and records information on any progression-of-care/patient flow barriers.
• Actively participates in daily huddles, multidisciplinary rounds and patient care conferences to maintain knowledge about intensity of services and the progression of care.
• Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes.
• Educates members of the patient’s care team on the appropriate access to and use of various levels of care.
• Promotes use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care.
• Serves as a resource person to physicians, care coordinators, physician offices and billing office for coverage and compliance issues.
• Works closely with decision support staff to review resource utilization data and trends to identify outliers who may benefit from real-time coaching to improve outcomes.
• Completes all reviews within department established policies and best practice standards. Meets department quality standards as established for the department, ie: Inter-rater Reliability audits, completing all initial reviews within established time frames, completes concurrent and discharge reviews to meet department and industry standards.
• Performs other duties as assigned.

SECURITY AND EEO STATEMENT
Security
This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information.

EEO Statement
UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.