Job Description
The mission of The University of Texas MD Anderson Cancer Center is to eliminate cancer in Texas, the nation, and the world through outstanding programs that integrate patient care, research and prevention, and through education for undergraduate and graduate students, trainees, professionals, employees and the public.
The primary purpose of the Utilization Review Nurse position is to:
Evaluate the necessity, appropriateness, and efficient use of medical services, procedures and setting in which the patient receives care
Ensure appropriate payment of services that includes review of the appropriate patient class, providing clinical reviews to payers utilizing specified guidelines, and facilitate timely peer to peer or appeals to mitigate denials
KEY FUNCTIONS
Standards of Practice â₠" Utilization Review Concepts
Applies approved clinical criteria and payer related guidelines to monitor appropriateness of admission, continued stays and level of care and documents findings according to departmental guidelines
Utilizes clinical knowledge and experience to abstract key information from the medical record and provides a clear understanding of the need for current bed status
Demonstrates ability to work independently and exercise sound judgment in interactions with physicians, members of the interdisciplinary team, internal and external customers, patients and their families
Demonstrates excellent interpersonal communication and negotiation skills
Demonstrates strong organizational and time management skills as evidenced by ability to prioritize and manage multiple tasks and role components
Utilization Review Activities
Ensures the admission order is accurate and correlates with the displayed patient class
Collaborates and communicates with the Case Manager on payer related issues that may impact the patientâ₠™s continuity of care (such as being out of network or underfunded)
Discusses patient status with medical team when order or documentation does not support the patient class
Documents all correspondence with payer and medical team according to department guidelines
Performs and documents utilization reviews according to established Departmental Utilization Review Guidelines
Monitors patients in Observation & Extended Recovery status and initiates appropriate actions
Interface with payor to provide clinical information as required to support medical necessity for services
Ensures utilization review case closures are completed within 4 business days post discharge
Serves as an expert resource and support to onsite review nurses and Utilization Review Specialist
Completes level of care (LOC) assessments on all assigned patients and identifies all avoidable days/delays as appropriate.
Performs necessary interventions to prevent denials, as appropriate
Facilitates peer to peer review related to denials for failure to meet acute care criteria within one business day from notification
Follows up with next level of appeal within 5 business days and escalates as appropriate
Maintains working knowledge of applicable payer-based rules for bed status determination and changes (such as Condition Code 44 and Medicare Inpatient only List)
Attends all mandatory departmental staff and team meetings and training sessions
Assigns role as Utilization Review Nurse in EPIC
Discuss payor criteria and concerns in a timely manner with the physician and interdisciplinary team to resolve issues/concerns with payors
Identifies self-pay patients and follows up to ensure if actual self-pay, refer to Patient Access Center for financial assessment.
Completes ACMA Compass training annually
Documentation
Reconciles patient days, next review dates and authorizations in EPIC
Includes appropriate chemo related medications, code and indications for use in clinicals
Documents daily Utilization Review activities appropriately in EPIC to reflect correspondence prior to the close of the business day
Utilizes sticky notes and handoff tools to communicate with medical team
Activates out of office notification on e-mail and voice mail with appropriate information prior to scheduled day off
Demonstrates compliance with all state and federal regulatory requirements
Facilitates authorizations for transfers back from Rehab to an acute care bed
Other duties as assigned
Education Required: Associate's degree in nursing (ADN).
Experience Required: Three years of experience as a Registered Nurse.
Licensure Required: Current State of Texas Professional Nursing License (RN). American Heart Association (AHA) Basic Life Support (BLS)
It is the policy of The University of Texas MD Anderson Cancer Center to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, disability, protected veteran status, genetic information, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law.
Additional Information
- Requisition ID: 174043
- Employment Status: Full-Time
- Employee Status: Regular
- Work Week: Day/Evening
- Minimum Salary: US Dollar (USD) 89,000
- Midpoint Salary: US Dollar (USD) 111,000
- Maximum Salary : US Dollar (USD) 133,000
- FLSA: exempt and eligible for overtime, paid at a straight rate
- Fund Type: Hard
- Work Location: Hybrid Onsite/Remote
- Pivotal Position: No
- Referral Bonus Available?: No
- Relocation Assistance Available?: No
- Science Jobs: No
#LI-Hybrid
Job Tags
Full time, Traineeship, Work at office, Local area, Relocation package, Afternoon shift,