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- Dallas, TX
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RN - Utilization Review - Health Plan Job
Children’s Health • Dallas, TX
Posted 11 days ago
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Responsible for concurrent and retrospective audit/review and tracking of acute and sub-acute clinical data to support and improve clinical outcomes. Ensure standards of care, regulatory and accreditation requirements are met. Collaborate with physicians and/or bedside care staff to address real time opportunities.
This RN will perform work at hospital locations, and will include telephonic office & remote work.
Essential Duties and Responsibilities
- Perform utilization review to include pre-certification, concurrent and retrospective review according to established guidelines
- Answer utilization directed phone calls as required
- Refer and discuss cases with the Medical Director when treatment requests do not meet medical necessity or when guidelines are not available
- Provide coaching and guidance to other UM Nurses
- Identify/report and refer all potential quality and fraud, waste and abuse issues
- Conducts single case agreements as needed with non-network Providers
- Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
- Two-year Associate's degree or equivalent experience, required
Licenses & certifications
- Current, unrestricted RN license in the State of Texas, required
- 2+ years experience in managed care or 5+ years as an RN, required
- Previous prior authorization/utilization management experience, preferred
- Previous InterQual or Milliman product use highly preferred
- ICD 9/10, CPT coding experience, preferred
Specific knowledge, skills and abilities
- Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
- Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
- Meet patient and patient family needs; take responsibility for a patient's safety, satisfaction, and clinical outcomes; use appropriate interpersonal techniques to resolve difficult patient situations and regain patient confidence.
- Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
- Develop and use collaborative relationships to facilitate the accomplishment of work goals.
- Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
- Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
- Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
- Effectively manage one's time and resources to ensure that work is completed efficiently.
- Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
- Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self impose standards of excellence rather than having standards imposed.
- Assimilate and apply new job-related information in a timely manner.
- Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.
- Duties require little or no exertion of physical effort.