Texas Health Resources Utilization Manager Reviewer - Registered Nurse - RN - SWHR CIN - Remote in Dallas, Texas
Southwestern Health Resources is seeking to hire a Utilization Manager Reviewer Registered Nurse to support our Southwestern Health Resources Utilization Management Department.
Location: Remote, must live in Dallas-Fort Worth area or willing to relocate to be considered.
Salary range is $34.74/hour – Max 50.05/hour – based on relevant experience.
• Full-time: 40 hours per week, Monday – Friday 8am-5pm
The 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 address
utilization/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.
The 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 of experience in direct patient care as an RN required
• 5 Years of experience in Health Plan Utilization Review, Discharge Planning and Medical Case Management preferred.
• Home Health Care experience highly preferred.
• Registered Nurse license upon hire required
• 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, etc
Southwestern 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.
Employment opportunities are only reflective of wholly owned Texas Health Resources entities.
We are an Equal Opportunity Employer and do not discriminate against any employees or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.