Utilization Review Nurse
Job Number: 378463
Location: 5323 Harry Hines Blvd, Dallas, TX
Department: 844106 - Decision Support
Full/Part Time/PRN: Day Job
Experience and Education
Graduate of accredited nursing program. BSN preferred.
Current TX RN license.
Current Basic Life Support (BLS) through American Heart Association.
RN, BSN with 6 years of clinical experience and utilization reviewexperience OR RN, CCM with 4 years experience in related field.
Prefer knowledge of InterQual and TMF care criteria.
- Collaborates with other disciplines, physicians and payers to assess, develop, implement and monitor a comprehensive plan of care to ensure continuity of care and cost effectiveness.
- Collaborates with physicians and staff regarding medical necessity for admission, continued stay or alternative treatment facilities/levels of care.
- Consistently relates utilization assessment to payers that are needed to justify continued stay review and to obtain pre-certification.
- Collaborates with physicians, payers and other disciplines to assess and document appropriateness of inpatient admission to the hospital or outpatient/observation status using Interqual criteria in Epic CCM.
- Relates utilization assessment to payers in a timely manner to justify admission and continued stay.
- Identifies avoidable days.
- Communicates effectively with other health care providers and payers.
- Evaluates outcomes data to identify trends and areas for improvement.
- Monitors potential admissions from the ED to make sure the appropriate level of care is identified.
- On a concurrent basis, assesses appropriateness of the level of care.
- Evaluates effectiveness of care and facilitates coordination of care toward specific outcomes criteria.
- Maintains timely documentation; consistently meets department and UH documentation standards.
- Identifies quality and risk issues, makes appropriate referrals.
- Confers with supervisor and/or Medical Director as appropriate.
- Communicates effectively with other health care providers, patients, families, other hospital personnel and visitors.
- Demonstrates effective communication with adolescents, adults and older adults.
- Knowledgeable of Department Performance Improvement Program and is aware of the expected participation.
- Collaborates with Social Work and others to arrange discharge planning referrals per physician orders.
- Identifies the need for professional growth and seeks appropriate development opportunities.
- Evaluates care management outcomes data to identify trends and areas for improvement (i.e. avoidable day, denial information).
- Perform other duties as assigned.
UTSouthwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. In accordance with federal and state law, the University prohibits unlawful discrimination, including harassment, on the basis of: race; color; religion; national origin; sex; including sexual harassment; age; disability; genetic information; citizenship status; and protected veteran status. In addition, it is UTSouthwestern policy to prohibit discrimination on the basis of sexual orientation, gender identity, or gender expression.