Under the direction of the Medical Management Director, the Utilization Management (UM) Nurse is responsible for analyzing clinical information submitted by medical providers to evaluate the medical necessity, appropriateness and efficiency of the use of medical services, procedures and facilities. The UM Nurse is also expected to maintain valid, unencumbered licensure in any region that the health plan operates. The UM Nurse is responsible for clinical review of all requested services for medical necessity based upon evidence based clinical guidelines. The UM Nurse is also responsible for making phone calls to providers to address post-hospital discharge services, redirection to in network providers for appropriate steerage, durable equipment usage and utilization of other medical services and/or procedures and other telephonic follow-up as identified by the UM Nurse, the Medical Management Clinical Supervisor or Medical Management Director. The UM Nurse is responsible for telephonic availability during non-business hours to assist with medical necessity reviews for medical services, procedures or facility usage. The UM Nurse promotes quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence based clinical guidelines. The UM Nurse will also utilize the nursing process and critical thinking skills to provide oversight of services and evaluation of service options.
Proactively analyze information submitted by providers to make timely medical necessity review determinations based upon evidence based clinical criteria and standards within governmental and contractual guidelines
Identify and present cases of possible quality of care deviations, questionable admissions and prolonged lengths of stay to the Medical Director for further determination
Collects accurate data for system input by using correct coding of diagnoses and/or procedures
Processes authorization requests via phone queue according to internal departmental processes.
Performs selected provider calls to address post-hospital discharge services, redirection to in network providers for appropriate steerage, durable equipment usage and utilization of other medical services and/or procedures and other telephonic follow-up as identified by the UM Nurse, the Medical Management Clinical Supervisor or Medical Management Director.
Maintain documentation of all contacts with providers for health management activities to meet all regulatory and contractual requirements.
Be available for after-hours telephonic utilization review needs of providers as mandated by governmental and contractual guidelines
Establishes and maintain rapport with providers as well as ongoing education of providers concerning appropriate protocol.
Appropriately refers member for case management services who have complex case management, transition of care, disease management or other identifiable needs for coordination of the member's health care.
Refers member who have high dollar utilization needs to dedicated health plan staff and reinsurance provider.
Support cost effective care by assuring in-network resources are being used in a timely manner whenever possible. Collaborate with provider relations for out of network contracting as needed.
Collaborates with and maintains open communication with all other departments as appropriate and required to facilitate completion of all tasks and goals
Follow the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
Protects confidentiality of data and intellectual property; assures compliance with national health information guidelines.
Adhere to URAC and NCQA Standards
Maintain valid, unencumbered licensure in all states, regions or territories that the health plan operates.
Maintains all professional CEU's in compliance with State and Regulatory requirements.
Utilize critical thinking skills, clinical judgement and the nursing process to evaluate the need for requested clinical services, processes or facility use.
Communication, Collaboration and Coordination with all customers, internal and external
Maintain clinical competencies by attendance at selected nursing meetings and/or documentation of educational activities.
Attend bi-weekly departmental staff meetings.
Ability to sit for long periods of time.
Ability to organize and prioritize work to meet contractual deadlines.
Ability to work occasional long or irregular hours to meet business needs.
Good speaking ability, judgement and initiative.
Ability to work a flexible work schedule including evening and weekends.
Demonstrate organizational, time management, prioritization and team-work skills.
Work autonomously and be directly accountable for results.
Function effectively in a fluid, dynamic, and changing environment.
Nursing School Diploma, Associate or Bachelor's Degree in Nursing required; Bachelor's Degree preferred
Valid unencumbered Texas RN licenseCompetent in Microsoft software (e.g. Word and Excel)
General computer knowledge and capability to use computers required.
Proficient typing skills.
Excellent telephonic customer service skills.
Excellent communication skills, (written and verbal) judgment, initiative, critical thinking and problem-solving abilities
Superior clinical judgement
Minimum of 3-5 years experience of direct patient clinical care
Minimum of 1-3 years experience in a managed care environment or health plan preferred
Ability to work in a variety of settings with culturally-diverse communities with the ability to be culturally sensitive and appropriate
Knowledge of managed care principles, HMO and Risk Contracting arrangements.
Licenses, Registrations, or Certifications
Licensed registered nurse (current and unrestricted) in the State of Texas
Obtain RN licensure within 3 months of hire in any other State that health plan operates and licensure is required
Certification in Case Management preferred or must be achieved within two years of hire.
Our Mission: WHY WE EXIST. To extend the healing ministry of Jesus Christ. Our Core Values: WHAT WE BELIEVE IN.DIGNITY Respect for the worth of every person, recognition and commitment to the value of diverse individuals and perspectives, and special concern for the poor and underserved. INTEGRITY Honesty, justice, and consistency in all relationships. EXCELLENCE High standards of service and performance. COMPASSION Service in a spirit of empathy, love, and concern. STEWARDSHIP Wise and just use of talents and resources in a collaborative manner.Our Vision: WHAT WE ARE STRIVING TO DO. CHRISTUS HEALTH, a Catholic health ministry, will be a leader, a partner and an advocate in the creation of innovative health and wellness solutions that improve the lives of individuals and communities so that all may experience God's healing presence and love. Our Name and Symbol:WHO WE ARE. CHRISTUS is Latin for "Christ," and proclaims publicly the core of our mission. OUR NAME choice also recognizes the heritage of our two congregational sponsors, the Sisters of Charity of the Incarnate Word in Houston and San Antonio. Jesus Christ is the Incarnate Word, the Word of God made flesh. It is, theref...ore, only fitting that it is in another form of His name that our health ministries are called together. OUR SYMBOL Reflects the healing ministry of Jesus Christ - a combination of a medical cross and a religious cross. The flowing banner on the cross is a common symbol of the risen Christ, while the royal purple signifies Christ. The flowing banner also conveys a sense of motion as we move forward into a new era of service to our communities.