PRN Utilization Review RN - M-F

Job Description

Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence‑based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations and documentation requirements.

With over 75 years of excellence in Dallas‑Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world‑renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the number 1 hospital in Dallas‑Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals.

Our highly competitive benefits package offers healthcare, PTO and paid holidays, on‑site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you’ll discover a culture of teamwork, professionalism, and a rewarding career!

Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence‑based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations and documentation requirements.

• PPO medical plan, available day one at no cost for full‑time employee‑only coverage
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer

• Education: Graduate of accredited nursing program and holds an active unrestricted RN license in the State of Texas
• Experience: 5 years experience, including 2 years of clinical experience and a minimum of 3 years of recent utilization review experience, and prior experience with Epic CCM.
• Licenses and
  
  Certifications:
  
  (RN) Registered Nurse holds an active unrestricted license in the State of Texas.

Preferred qualifications or skills (not explicitly listed in the source).

• Collaborates with the Central Scheduling Department (CSD) team to provide accurate and complete clinical information in order to obtain authorization.
• Conducts admission reviews for Medicare and Medicaid beneficiaries as well as private insurance members and self‑pay patients utilizing evidence‑based guidelines.
• New admission reviews are done concurrently at the point of entry when the admission order is placed and necessary clinical information is available in the medical record.
• Communicate with admitting physicians and physician advisors when documentation does not appear to support hospital level of care.
• Use hospital approved medical necessity tool to determine level of care for inpatient or observation/outpatient services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two‑midnight stay.
• Keeps current on all Federal, State and local regulatory changes that affect delivery or reimbursement of acute care services within the scope of Utilization Management. Uses knowledge of national and local coverage determinations to appropriately advise physicians.
• Proactively collaborates with admitting physician to provide accurate level of care determination at the time of review.
• Escalates identified progression‑of‑care/patient flow barriers to appropriate departments.
• Actively participates in daily huddles, departmental meetings and education offerings.
• Identifies and records episodes of preventable delays or avoidable days due to failure of progression‑of‑care processes.
• Educates members of the patient's care team on the appropriate access to and use of various levels of care.
• Promotes use of evidence‑based protocols and/or order sets to influence high‑quality…