Utilization Management Nurse III

Company: Christus Health
Location: San Antonio
Posted on: September 29, 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, Round Rock , Utilization Management Nurse III, Executive , San Antonio, Texas