Utilization Management Nurse II - Case Management (Tyler)

75701 Tyler, Texas Christus Health

Posted today

Job Viewed

Tap Again To Close

Job Description

Description

Summary:

The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services CMS Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and Joint Commission regulations and guidelines related to UM. This Nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Management Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.

Responsibilities:

  • Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
  • Applies demonstrated clinical competency and judgment in order to perform comprehensive assessments of clinical information and treatment plans and apply medical necessity criteria in order to determine the appropriate level of care.
  • Resource/Utilization Management appropriateness: Assess assigned patient population for medical necessity, level of care, and appropriateness of setting and services. Utilizes MCG/InterQual Care Guidelines and/or health system-approved tools to track impact and variance.
  • Uses appropriate criteria sets for admission reviews, continued stay reviews, outlier reviews, and clinical appropriateness recommendations.
  • Coordinate and facilitate correct identification of patient status.
  • Analyze the quality and comprehensiveness of documentation and collaborate with the physician and treatment team to obtain documentation needed to support the level of care.
  • Facilitates joint decision-making with the interdisciplinary team regarding any changes in the patient status and/or negative outcomes in patient responses.
  • Demonstrates, maintains, and applies current knowledge of regulatory requirements relative to the work process in order to ensure compliance, i. e. IMM, Code 44.
  • Demonstrate adherence to the CORE values of CHRISTUS.
  • Utilize independent scope of practice to identify, evaluate and provide utilization review services for patients and analyze information supplied by physicians (or other clinical staff) to make timely review determinations, based on appropriate criteria and standards.
  • Take appropriate follow-up action when established criteria for utilization of services are not met.
  • Proactively refer cases to the physician advisor for medical necessity reviews, peer-to-peer reviews, and denial avoidance.
  • Effectively collaborate with the Interdisciplinary team including the Physician Advisor for secondary reviews.
  • Proactively review patients at the point of entry, prior to admission, to determine the medical necessity of a requested hospitalization and the appropriate level of care or placement for the patient.
  • Review surgery schedule to ensure planned surgeries are ordered in the appropriate status and that necessary authorization has been obtained as required by the payor or regulatory guidance (i. e., CMS Inpatient Only List, Payor Prior Authorization matrix, etc.)
  • Regularly review patients who are in the hospital in Observation status to determine if the patient is appropriate for discharge or if conversion to inpatient status is appropriate.
  • 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 as per payor or regulatory requirements to coordinate certification of hospital services.
  • Coordinate and facilitate patient care progression throughout the continuum and communicate and document to support medical necessity at each level of care.
  • Evaluate care administered by the interdisciplinary health care team and advocate for standards of practice.
  • Analyze assessment data to identify potential problems and formulate goals/outcomes.
  • Follows the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability ACT (HIPPA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
  • Attend scheduled department staff meetings and/or interdepartmental meetings as appropriate.
  • Possesses and demonstrates technology literacy and the ability to work in multiple technology systems.
  • Act as a catalyst for change in the organization; respond to change with flexibility and adaptability; demonstrate the ability to work together for change.
  • Translate strategies into action steps; monitor progress and achieve results.
  • Demonstrate the 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 the population-specific and developmental needs of patients served by the department.
  • Possess negotiating skills that support the 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, particularly coverage and limitation clauses.
  • 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 the medical record per regulatory and department guidelines.
  • May be asked to assist with special projects.
  • May serve as a preceptor or orienter to new associates.
  • Assumes responsibility for professional growth and development.
  • Familiarity with criteria sets including InterQual and MCG preferred.
  • Must have excellent verbal and written communication and ability to interact with diverse populations.
  • Must have critical and analytical thinking skills.
  • Must have demonstrated clinical competency.
  • Must have the ability to Multitask and to function in a stressful and fast-paced environment.
  • Must have working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
  • Must have an understanding of pre-acute and post-acute levels of care and community resources.
  • Must have the ability to work independently and exercise sound judgment in interactions with physicians, payors, patients, and their families.
  • Must have an understanding of internal and external resources and knowledge of available community resources.
  • Other duties as assigned.

Job Requirements:

Education/Skills

  • Graduate of an accredited School of Nursing OR demonstrated success in the Utilization Management Nurse I role for at least five years at CHRISTUS Health on top of required experience in lieu of education required.

Experience

  • Two or more years of clinical experience with at least one year in the acute care setting OR demonstrated success as Utilization Management Nurse I role at CHRISTUS Health required.

Licenses, Registrations, or Certifications

  • RN License in state of employment or compact required.
  • LPN or LVN license accepted for associates with 5+ years of demonstrated success and experience in the Utilization Management Nurse I role at CHRISTUS Health.
  • Certification in Case Management preferred.
  • BLS preferred.

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time

View Now

Utilization Management Nurse II - Case Management (Tyler)

75701 Tyler, Texas Christus Health

Posted today

Job Viewed

Tap Again To Close

Job Description

Description

Summary:

The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services CMS Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and Joint Commission regulations and guidelines related to UM. This Nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Management Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.

Responsibilities:

  • Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
  • Applies demonstrated clinical competency and judgment in order to perform comprehensive assessments of clinical information and treatment plans and apply medical necessity criteria in order to determine the appropriate level of care.
  • Resource/Utilization Management appropriateness: Assess assigned patient population for medical necessity, level of care, and appropriateness of setting and services. Utilizes MCG/InterQual Care Guidelines and/or health system-approved tools to track impact and variance.
  • Uses appropriate criteria sets for admission reviews, continued stay reviews, outlier reviews, and clinical appropriateness recommendations.
  • Coordinate and facilitate correct identification of patient status.
  • Analyze the quality and comprehensiveness of documentation and collaborate with the physician and treatment team to obtain documentation needed to support the level of care.
  • Facilitates joint decision-making with the interdisciplinary team regarding any changes in the patient status and/or negative outcomes in patient responses.
  • Demonstrates, maintains, and applies current knowledge of regulatory requirements relative to the work process in order to ensure compliance, i. e. IMM, Code 44.
  • Demonstrate adherence to the CORE values of CHRISTUS.
  • Utilize independent scope of practice to identify, evaluate and provide utilization review services for patients and analyze information supplied by physicians (or other clinical staff) to make timely review determinations, based on appropriate criteria and standards.
  • Take appropriate follow-up action when established criteria for utilization of services are not met.
  • Proactively refer cases to the physician advisor for medical necessity reviews, peer-to-peer reviews, and denial avoidance.
  • Effectively collaborate with the Interdisciplinary team including the Physician Advisor for secondary reviews.
  • Proactively review patients at the point of entry, prior to admission, to determine the medical necessity of a requested hospitalization and the appropriate level of care or placement for the patient.
  • Review surgery schedule to ensure planned surgeries are ordered in the appropriate status and that necessary authorization has been obtained as required by the payor or regulatory guidance (i. e., CMS Inpatient Only List, Payor Prior Authorization matrix, etc.)
  • Regularly review patients who are in the hospital in Observation status to determine if the patient is appropriate for discharge or if conversion to inpatient status is appropriate.
  • 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 as per payor or regulatory requirements to coordinate certification of hospital services.
  • Coordinate and facilitate patient care progression throughout the continuum and communicate and document to support medical necessity at each level of care.
  • Evaluate care administered by the interdisciplinary health care team and advocate for standards of practice.
  • Analyze assessment data to identify potential problems and formulate goals/outcomes.
  • Follows the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability ACT (HIPPA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
  • Attend scheduled department staff meetings and/or interdepartmental meetings as appropriate.
  • Possesses and demonstrates technology literacy and the ability to work in multiple technology systems.
  • Act as a catalyst for change in the organization; respond to change with flexibility and adaptability; demonstrate the ability to work together for change.
  • Translate strategies into action steps; monitor progress and achieve results.
  • Demonstrate the 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 the population-specific and developmental needs of patients served by the department.
  • Possess negotiating skills that support the 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, particularly coverage and limitation clauses.
  • 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 the medical record per regulatory and department guidelines.
  • May be asked to assist with special projects.
  • May serve as a preceptor or orienter to new associates.
  • Assumes responsibility for professional growth and development.
  • Familiarity with criteria sets including InterQual and MCG preferred.
  • Must have excellent verbal and written communication and ability to interact with diverse populations.
  • Must have critical and analytical thinking skills.
  • Must have demonstrated clinical competency.
  • Must have the ability to Multitask and to function in a stressful and fast-paced environment.
  • Must have working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
  • Must have an understanding of pre-acute and post-acute levels of care and community resources.
  • Must have the ability to work independently and exercise sound judgment in interactions with physicians, payors, patients, and their families.
  • Must have an understanding of internal and external resources and knowledge of available community resources.
  • Other duties as assigned.

Job Requirements:

Education/Skills

  • Graduate of an accredited School of Nursing OR demonstrated success in the Utilization Management Nurse I role for at least five years at CHRISTUS Health on top of required experience in lieu of education required.

Experience

  • Two or more years of clinical experience with at least one year in the acute care setting OR demonstrated success as Utilization Management Nurse I role at CHRISTUS Health required.

Licenses, Registrations, or Certifications

  • RN License in state of employment or compact required.
  • LPN or LVN license accepted for associates with 5+ years of demonstrated success and experience in the Utilization Management Nurse I role at CHRISTUS Health.
  • Certification in Case Management preferred.
  • BLS preferred.

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time

View Now

Utilization Management Nurse II - Case Management (Tyler)

75701 Tyler, Texas Christus Health

Posted today

Job Viewed

Tap Again To Close

Job Description

Description

Summary:

The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services CMS Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and Joint Commission regulations and guidelines related to UM. This Nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Management Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.

Responsibilities:

  • Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
  • Applies demonstrated clinical competency and judgment in order to perform comprehensive assessments of clinical information and treatment plans and apply medical necessity criteria in order to determine the appropriate level of care.
  • Resource/Utilization Management appropriateness: Assess assigned patient population for medical necessity, level of care, and appropriateness of setting and services. Utilizes MCG/InterQual Care Guidelines and/or health system-approved tools to track impact and variance.
  • Uses appropriate criteria sets for admission reviews, continued stay reviews, outlier reviews, and clinical appropriateness recommendations.
  • Coordinate and facilitate correct identification of patient status.
  • Analyze the quality and comprehensiveness of documentation and collaborate with the physician and treatment team to obtain documentation needed to support the level of care.
  • Facilitates joint decision-making with the interdisciplinary team regarding any changes in the patient status and/or negative outcomes in patient responses.
  • Demonstrates, maintains, and applies current knowledge of regulatory requirements relative to the work process in order to ensure compliance, i. e. IMM, Code 44.
  • Demonstrate adherence to the CORE values of CHRISTUS.
  • Utilize independent scope of practice to identify, evaluate and provide utilization review services for patients and analyze information supplied by physicians (or other clinical staff) to make timely review determinations, based on appropriate criteria and standards.
  • Take appropriate follow-up action when established criteria for utilization of services are not met.
  • Proactively refer cases to the physician advisor for medical necessity reviews, peer-to-peer reviews, and denial avoidance.
  • Effectively collaborate with the Interdisciplinary team including the Physician Advisor for secondary reviews.
  • Proactively review patients at the point of entry, prior to admission, to determine the medical necessity of a requested hospitalization and the appropriate level of care or placement for the patient.
  • Review surgery schedule to ensure planned surgeries are ordered in the appropriate status and that necessary authorization has been obtained as required by the payor or regulatory guidance (i. e., CMS Inpatient Only List, Payor Prior Authorization matrix, etc.)
  • Regularly review patients who are in the hospital in Observation status to determine if the patient is appropriate for discharge or if conversion to inpatient status is appropriate.
  • 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 as per payor or regulatory requirements to coordinate certification of hospital services.
  • Coordinate and facilitate patient care progression throughout the continuum and communicate and document to support medical necessity at each level of care.
  • Evaluate care administered by the interdisciplinary health care team and advocate for standards of practice.
  • Analyze assessment data to identify potential problems and formulate goals/outcomes.
  • Follows the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability ACT (HIPPA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
  • Attend scheduled department staff meetings and/or interdepartmental meetings as appropriate.
  • Possesses and demonstrates technology literacy and the ability to work in multiple technology systems.
  • Act as a catalyst for change in the organization; respond to change with flexibility and adaptability; demonstrate the ability to work together for change.
  • Translate strategies into action steps; monitor progress and achieve results.
  • Demonstrate the 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 the population-specific and developmental needs of patients served by the department.
  • Possess negotiating skills that support the 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, particularly coverage and limitation clauses.
  • 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 the medical record per regulatory and department guidelines.
  • May be asked to assist with special projects.
  • May serve as a preceptor or orienter to new associates.
  • Assumes responsibility for professional growth and development.
  • Familiarity with criteria sets including InterQual and MCG preferred.
  • Must have excellent verbal and written communication and ability to interact with diverse populations.
  • Must have critical and analytical thinking skills.
  • Must have demonstrated clinical competency.
  • Must have the ability to Multitask and to function in a stressful and fast-paced environment.
  • Must have working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
  • Must have an understanding of pre-acute and post-acute levels of care and community resources.
  • Must have the ability to work independently and exercise sound judgment in interactions with physicians, payors, patients, and their families.
  • Must have an understanding of internal and external resources and knowledge of available community resources.
  • Other duties as assigned.

Job Requirements:

Education/Skills

  • Graduate of an accredited School of Nursing OR demonstrated success in the Utilization Management Nurse I role for at least five years at CHRISTUS Health on top of required experience in lieu of education required.

Experience

  • Two or more years of clinical experience with at least one year in the acute care setting OR demonstrated success as Utilization Management Nurse I role at CHRISTUS Health required.

Licenses, Registrations, or Certifications

  • RN License in state of employment or compact required.
  • LPN or LVN license accepted for associates with 5+ years of demonstrated success and experience in the Utilization Management Nurse I role at CHRISTUS Health.
  • Certification in Case Management preferred.
  • BLS preferred.

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time

View Now

Utilization Management Nurse II - Case Management (Tyler)

75701 Tyler, Texas Christus Health

Posted today

Job Viewed

Tap Again To Close

Job Description

Description

The information below covers the role requirements, expected candidate experience, and accompanying qualifications.

Summary:



The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services CMS Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and Joint Commission regulations and guidelines related to UM. This Nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Management Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.



Responsibilities:



  • Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
  • Applies demonstrated clinical competency and judgment in order to perform comprehensive assessments of clinical information and treatment plans and apply medical necessity criteria in order to determine the appropriate level of care.
  • Resource/Utilization Management appropriateness: Assess assigned patient population for medical necessity, level of care, and appropriateness of setting and services. Utilizes MCG/InterQual Care Guidelines and/or health system-approved tools to track impact and variance.
  • Uses appropriate criteria sets for admission reviews, continued stay reviews, outlier reviews, and clinical appropriateness recommendations.
  • Coordinate and facilitate correct identification of patient status.
  • Analyze the quality and comprehensiveness of documentation and collaborate with the physician and treatment team to obtain documentation needed to support the level of care.
  • Facilitates joint decision-making with the interdisciplinary team regarding any changes in the patient status and/or negative outcomes in patient responses.
  • Demonstrates, maintains, and applies current knowledge of regulatory requirements relative to the work process in order to ensure compliance, i. e. IMM, Code 44.
  • Demonstrate adherence to the CORE values of CHRISTUS.
  • Utilize independent scope of practice to identify, evaluate and provide utilization review services for patients and analyze information supplied by physicians (or other clinical staff) to make timely review determinations, based on appropriate criteria and standards.
  • Take appropriate follow-up action when established criteria for utilization of services are not met.
  • Proactively refer cases to the physician advisor for medical necessity reviews, peer-to-peer reviews, and denial avoidance.
  • Effectively collaborate with the Interdisciplinary team including the Physician Advisor for secondary reviews.
  • Proactively review patients at the point of entry, prior to admission, to determine the medical necessity of a requested hospitalization and the appropriate level of care or placement for the patient.
  • Review surgery schedule to ensure planned surgeries are ordered in the appropriate status and that necessary authorization has been obtained as required by the payor or regulatory guidance (i. e., CMS Inpatient Only List, Payor Prior Authorization matrix, etc.)
  • Regularly review patients who are in the hospital in Observation status to determine if the patient is appropriate for discharge or if conversion to inpatient status is appropriate.
  • 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 as per payor or regulatory requirements to coordinate certification of hospital services.
  • Coordinate and facilitate patient care progression throughout the continuum and communicate and document to support medical necessity at each level of care.
  • Evaluate care administered by the interdisciplinary health care team and advocate for standards of practice.
  • Analyze assessment data to identify potential problems and formulate goals/outcomes.
  • Follows the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability ACT (HIPPA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
  • Attend scheduled department staff meetings and/or interdepartmental meetings as appropriate.
  • Possesses and demonstrates technology literacy and the ability to work in multiple technology systems.
  • Act as a catalyst for change in the organization; respond to change with flexibility and adaptability; demonstrate the ability to work together for change.
  • Translate strategies into action steps; monitor progress and achieve results.
  • Demonstrate the 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 the population-specific and developmental needs of patients served by the department.
  • Possess negotiating skills that support the 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, particularly coverage and limitation clauses.
  • 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 the medical record per regulatory and department guidelines.
  • May be asked to assist with special projects.
  • May serve as a preceptor or orienter to new associates.
  • Assumes responsibility for professional growth and development.
  • Familiarity with criteria sets including InterQual and MCG preferred.
  • Must have excellent verbal and written communication and ability to interact with diverse populations.
  • Must have critical and analytical thinking skills.
  • Must have demonstrated clinical competency.
  • Must have the ability to Multitask and to function in a stressful and fast-paced environment.
  • Must have working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
  • Must have an understanding of pre-acute and post-acute levels of care and community resources.
  • Must have the ability to work independently and exercise sound judgment in interactions with physicians, payors, patients, and their families.
  • Must have an understanding of internal and external resources and knowledge of available community resources.
  • Other duties as assigned.


Job Requirements:



Education/Skills



  • Graduate of an accredited School of Nursing OR demonstrated success in the Utilization Management Nurse I role for at least five years at CHRISTUS Health on top of required experience in lieu of education required.

Experience



  • Two or more years of clinical experience with at least one year in the acute care setting OR demonstrated success as Utilization Management Nurse I role at CHRISTUS Health required.

Licenses, Registrations, or Certifications



  • RN License in state of employment or compact required.
  • LPN or LVN license accepted for associates with 5+ years of demonstrated success and experience in the Utilization Management Nurse I role at CHRISTUS Health.
  • Certification in Case Management preferred.
  • BLS preferred.


Work Schedule:



5 Days - 8 Hours



Work Type:



Full Time

View Now

Utilization Management Nurse II - Case Management - Full Time (Longview)

New
75606 Liberty City, Texas Christus Health

Posted today

Job Viewed

Tap Again To Close

Job Description

Description

Summary:

The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services CMS Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and Joint Commission regulations and guidelines related to UM. This Nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Management Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.


Responsibilities:

  • Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
  • Applies demonstrated clinical competency and judgment in order to perform comprehensive assessments of clinical information and treatment plans and apply medical necessity criteria in order to determine the appropriate level of care.
  • Resource/Utilization Management appropriateness: Assess assigned patient population for medical necessity, level of care, and appropriateness of setting and services. Utilizes MCG/InterQual Care Guidelines and/or health system-approved tools to track impact and variance.
  • Uses appropriate criteria sets for admission reviews, continued stay reviews, outlier reviews, and clinical appropriateness recommendations.
  • Coordinate and facilitate correct identification of patient status.
  • Analyze the quality and comprehensiveness of documentation and collaborate with the physician and treatment team to obtain documentation needed to support the level of care.
  • Facilitates joint decision-making with the interdisciplinary team regarding any changes in the patient status and/or negative outcomes in patient responses.
  • Demonstrates, maintains, and applies current knowledge of regulatory requirements relative to the work process in order to ensure compliance, i. e. IMM, Code 44.
  • Demonstrate adherence to the CORE values of CHRISTUS.
  • Utilize independent scope of practice to identify, evaluate and provide utilization review services for patients and analyze information supplied by physicians (or other clinical staff) to make timely review determinations, based on appropriate criteria and standards.
  • Take appropriate follow-up action when established criteria for utilization of services are not met.
  • Proactively refer cases to the physician advisor for medical necessity reviews, peer-to-peer reviews, and denial avoidance.
  • Effectively collaborate with the Interdisciplinary team including the Physician Advisor for secondary reviews.
  • Proactively review patients at the point of entry, prior to admission, to determine the medical necessity of a requested hospitalization and the appropriate level of care or placement for the patient.
  • Review surgery schedule to ensure planned surgeries are ordered in the appropriate status and that necessary authorization has been obtained as required by the payor or regulatory guidance (i. e., CMS Inpatient Only List, Payor Prior Authorization matrix, etc.)
  • Regularly review patients who are in the hospital in Observation status to determine if the patient is appropriate for discharge or if conversion to inpatient status is appropriate.
  • 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 as per payor or regulatory requirements to coordinate certification of hospital services.
  • Coordinate and facilitate patient care progression throughout the continuum and communicate and document to support medical necessity at each level of care.
  • Evaluate care administered by the interdisciplinary health care team and advocate for standards of practice.
  • Analyze assessment data to identify potential problems and formulate goals/outcomes.
  • Follows the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability ACT (HIPPA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
  • Attend scheduled department staff meetings and/or interdepartmental meetings as appropriate.
  • Possesses and demonstrates technology literacy and the ability to work in multiple technology systems.
  • Act as a catalyst for change in the organization; respond to change with flexibility and adaptability; demonstrate the ability to work together for change.
  • Translate strategies into action steps; monitor progress and achieve results.
  • Demonstrate the 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 the population-specific and developmental needs of patients served by the department.
  • Possess negotiating skills that support the 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, particularly coverage and limitation clauses.
  • 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 the medical record per regulatory and department guidelines.
  • May be asked to assist with special projects.
  • May serve as a preceptor or orienter to new associates.
  • Assumes responsibility for professional growth and development.
  • Familiarity with criteria sets including InterQual and MCG preferred.
  • Must have excellent verbal and written communication and ability to interact with diverse populations.
  • Must have critical and analytical thinking skills.
  • Must have demonstrated clinical competency.
  • Must have the ability to Multitask and to function in a stressful and fast-paced environment.
  • Must have working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
  • Must have an understanding of pre-acute and post-acute levels of care and community resources.
  • Must have the ability to work independently and exercise sound judgment in interactions with physicians, payors, patients, and their families.
  • Must have an understanding of internal and external resources and knowledge of available community resources.
  • Other duties as assigned.


Job Requirements:

Education/Skills

  • Graduate of an accredited School of Nursing OR demonstrated success in the Utilization Management Nurse I role for at least five years at CHRISTUS Health on top of required experience in lieu of education required.

Experience

  • Two or more years of clinical experience with at least one year in the acute care setting OR demonstrated success as Utilization Management Nurse I role at CHRISTUS Health required.

Licenses, Registrations, or Certifications

  • RN License in state of employment or compact required.
  • LPN or LVN license accepted for associates with 5+ years of demonstrated success and experience in the Utilization Management Nurse I role at CHRISTUS Health.
  • Certification in Case Management preferred.
  • BLS preferred.

Work Schedule:

TBD


Work Type:

Full Time

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Waste Management, Inc. - As a Diesel Mechanic at Waste Management, you'll: Perform repairs and assigned preventive maintenance services; Perform inspection, diagnosis and repair of electrical, hydraulic, suspension, brake and air systems on vehicles and equipment; Utilize vehicle computer electronics systems to interpret failure modes to initiate/assign repairs; Conduct safety checks on vehicles.Hiring Immediately >>
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Waste Management is currently accepting applications for a Trash Collector! Primary duties of the Trash Collector include: - Operating garbage trucks - Collecting and dumping trash receptacles - Following route assignments as directed Waste Management offers an excellent benefits package that includes medical, dental, vision, life, 401(k) savings and more. Submit your application now to become a Trash Collector with Waste Management!
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Coordinator Sepsis - Quality Management

75701 Tyler, Texas CHRISTUS Health

Posted 3 days ago

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Description Summary: High Reliability Organization, the Coordinator Sepsis, reporting to the Director of Quality, is responsible for coordination activities of the Sepsis Clinical Improvement Program in the hospital. The Sepsis Coordinator works collaboratively with hospital and medical staff leadership to utilize data and evidence-based practice to drive strategies in performance improvement, regulatory, and patient safety activities that promote a culture of learning, improvement, and patient safety of the sepsis patient. Analyzes and reviews provided data for opportunities for improvement/process improvement to reduce the impact of sepsis and severe sepsis. This role is responsible for organizing and coordinating specific quality activities and for compiling/displaying/evaluating information from program for assigned hospital and medical staff committees and teams. This role is expected to apply clinical knowledge and analytical skills to assist the Director of QM and support change with a strong focus on improving quality outcomes and results. Responsibilities: Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders. Communicate effectively to different audiences. Proficient in computer skills using EXCEL, PowerPoint, MSOffice, and Flowchart tools. Knowledgeable on High Reliability Principles and PDSA methodology. Source: NAHQ Workforce Accelerator Competency Framework 2022: Eight Domains Quality Leadership and Integration-Advance the organization's commitment to health care quality through collaboration, learning opportunities and communication. Lead the integration of quality into the fabric of the organization through a coordinated infrastructure to achieve organizational objectives. Domain Level: Foundational. Performance and Process Improvement-Use performance and process improvement (PPI), project management and change management methods to support operational and clinical quality initiatives, improved performance and achieve organizational goals. Domain Level: Foundational. Population Health and Care Transitions-Evaluates and improve health care processes and care transitions to advance the efficient, effective, and safe care of defined populations. Domain Level: Foundational. Health Data and Analytics- Leverage the organizations analytic environment to help guide data-driven decision-making and inform quality improvement initiatives. Domain Level: Foundational. Regulatory and Accreditation-Direct organization wide processes for evaluating, monitoring, and improving compliance with internal and external requirements. Lead the organization's processes to prepare for, participate in, and follow up on regulatory, accreditation and certification surveys and activities. Domain Level: Foundational. Patients Safety-Cultivate a safe healthcare environment by promoting safe practices, nurturing a just culture, and improving processes that detect, mitigate, or prevent harm. Domain Level: Foundational. Quality Review and Accountability-Direct activities that support compliance with organization wide voluntary, mandatory, and contractual requirements for data acquisition, analysis, reporting, and improvement. Domain Level: Foundational. Professional Engagement-Engage in the healthcare quality profession with a commitment to practicing ethically, enhancing one's competence, and advancing the field. Domain Level: Foundational. Job Requirements: Education/Skills Associate degree in Nursing or other allied health required Bachelors degree preferred Experience 3 years of healthcare experience required 2 years of quality management experience preferred Licenses, Registrations, or Certifications Registered Nurse, Licensed Vocational/Practical Nurse, Registered Respiratory Therapist, or Paramedic licensure required in the state of practice CPHQ (Certified Professional in Healthcare Quality) preferred Work Schedule: 8AM - 5PM Monday-Friday Work Type: Full Timeaa415a4b-8b21-40fc-a65c-70d2b25ca29a

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