Harris Health System - Southwest Houston, TX
posted 19 days ago
Full-time - Mid Level
Remote - Southwest Houston, TX
Ambulatory Health Care Services
About the position
The Utilization Management Review Nurse (UMRN) at Harris Health System is responsible for evaluating the necessity, appropriateness, and efficiency of medical services and procedures. This role leverages clinical expertise and industry guidelines to ensure that patients receive care at the appropriate level based on medical necessity. The UMRN collaborates with various stakeholders, including Care Management and Physician Advisors, to promote quality care and cost-effective outcomes, while also addressing denials and appeals with payers.
Responsibilities
- Evaluate the necessity and appropriateness of medical services and procedures.
- Utilize clinical knowledge and industry guidelines to ensure appropriate care levels.
- Collaborate with Care Management, Physician Advisors, and Finance to enhance patient outcomes.
- Reconcile denials and reconsiderations with payers and assist with appeals as needed.
- Participate in quality improvement activities and promote a customer-friendly environment.
- Collect, analyze, and address variances from the care plan with healthcare team members.
Requirements
- Graduated from an accredited school of Nursing with a Bachelor's in Nursing.
- Licensed to practice nursing in the State of Texas as a Registered Nurse.
- Case Management Certification (ACM or CCM) within two years of hire.
- Basic Life Support certification from AHA or Red Cross approved program.
- 5 years of experience in acute healthcare settings, including 2 years in Case Management, Quality Management, or Utilization Management.
- Above average verbal communication skills and exceptional writing skills.
Nice-to-haves
- Bilingual skills preferred.
- Proficiency in MS Word, Excel, and PowerPoint.
- Experience with utilization review tools such as MCG or Change healthcare (Interqual).
Benefits
- Flexible work schedule with 8-hour shifts, variable to 10-12 hours as needed.
- Potential for telecommuting based on system needs.
