Utilization Review Nurse

At Houston Methodist the Utilization Review Nurse (URN) position is a licensed registered nurse (RN) who comprehensively conducts point of entry and concurrent medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff payer guidelines CMS and other state agencies. This position prospectively or concurrently determines the appropriateness of inpatient or observation services following review of relevant medical documentation medical guidelines and insurance benefits and communicates information to payers in accordance with contractual obligations. The URN position serves as a resource to the physicians and provides education and information on resource utilization and national and local coverage determinations (LCDs & NCDs). This position collaborates with case management in the development and implementation of the plan of care and ensures prompt notification of any denials to the appropriate case manager denials and prebill team members as well as management.

PATIENT AGE GROUP(S) AND POPULATION(S) SERVED
Refer to departmental Scope of Service and Provision of Care plans as applicable for description of primary age groups and populations served by this job for the respective HM entity.

HOUSTON METHODIST EXPERIENCE EXPECTATIONS

• Provide personalized care and service by consistently demonstrating our I CARE values:
  • INTEGRITY: We are honest and ethical in all we say and do.
  • COMPASSION: We embrace the whole person including emotional ethical physical and spiritual needs.
  • ACCOUNTABILITY: We hold ourselves accountable for all our actions.
  • RESPECT: We treat every individual as a person of worth dignity and value.
  • EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.

• Practices the Caring and Serving Model

• Delivers personalized service using HM Service Standards

• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET Managing Up Key Words)

• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees experiential journeys to ensure strong communication ease of access to information and a seamless experience

• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

• Actively supports the organizations vision fulfills the mission and abides by the I CARE values

PEOPLE ESSENTIAL FUNCTIONS

• Establishes and maintains effective professional working relationships with patients families interdisciplinary team members payers and external case managers; listens and responds to the ideas of others.

• Collaborates with the access management team to ensure accurate and complete clinical and payer information. Educates members of the patients healthcare team on the appropriate access to and use of various levels of care.

• Contributes towards improvement of department scores for employee engagement i.e. peertopeer accountability.

SERVICE ESSENTIAL FUNCTIONS

• Proactively participates as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patients preference reason for admission and availability of resources. Participates in daily Care Coordination Rounds and identifies and communicates barriers to efficient utilization.

• Reviews H&Ps and admitting orders of all direct transfer and emergency care patients designated for admission to ensure compliance with CMS guidelines regarding appropriateness of level of care.

• Identifies potentially unnecessary services and care delivery settings and recommends alternatives if appropriate by analyzing clinical protocols.

• Escalates appropriate cases to the Physician Advisor (or services) for appropriate second level review peerpeer discussions and payer denial appeal needs. Consults with physician advisor as necessary to resolve progressionofcare barriers through appropriate administrative and medical channels.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Participates in quality improvement activities as stewards for resource utilization as it pertains to medical necessity and level of care. Promotes medical documentation that accurately reflects intensity of services quality and safety indicators and patients need to continue stay.

• Promotes the use of evidencebased protocols and/or order sets to influence highquality and costeffective care. Identifies areas for improvement based on an understanding of evidencebased practice/performance improvement projects based on these observations.

• Identifies and records episodes of preventable delays or avoidable days due to failure of the progression of the care process

FINANCE ESSENTIAL FUNCTIONS

• Contributes to meeting department financial targets with a focus on appropriate utilization and denial prevention. Utilizes resources with cost effectiveness and value creation in mind. Selfmotivated to independently manage time effectively and prioritize daily tasks assisting coworkers as needed.

• Performs review for medical necessity of admission continued stay and resource use appropriate level of care and program compliance using evidencebased nationally recognized guidelines. Manages assigned patients and communicates and collaborates with the case manager to assist with appropriate interventions to avoid denial of payment.

• Collaborates with the revenue cycle regarding any claim issues or concerns that may require clinical review during the prebill audit or appeal process.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Identifies and presents areas for improvement in patient care or department operations and offers solutions by participating in department projects and activities.

• Seeks opportunities to identify selfdevelopment needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an ongoing basis.

This job description is not intended to be allinclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

EDUCATION

• Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications Licenses and Registrations section

• Bachelors degree preferred

WORK EXPERIENCE

• Three years of hospital clinical nursing experience which includes two years in case management

LICENSES AND CERTIFICATIONS REQUIRED

• RN Registered Nurse Texas State Licensure and/or Compact State Licensure within 60 days OR
• RNTemp Registered Nurse Temporary State Licensure within 60 days

KNOWLEDGE SKILLS AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job determined through ongoing skills competency assessments and performance evaluations

• Sufficient proficiency in speaking reading and writing the English language necessary to perform the essential functions of this job especially with regard to activities impacting patient or employee safety or security

• Ability to effectively communicate with patients physicians family members and coworkers in a manner consistent with a customer service focus and application of positive language principles

• Progressive knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and knowledge of local and national coverage determinations

• Recent work experience in a hospital or insurance company providing utilization review services

• Knowledge of Medicare Medicaid and Managed Care requirements

• Progressive knowledge of community resources health care financial and payer requirements/issues and eligibility for state local and federal programs

• Progressive knowledge of utilization management case management performance improvement and managed care reimbursement

• Ability to work independently and exercise sound judgment in interactions with physicians payers and health care team members

• Strong assessment organizational and problemsolving skills

• Maintains level of professional contributions as defined in Career Path program

• Understands and applies federal law regarding the use of Hospital Initiated Notice of NonCoverage (HINN) Ambulatory Benefit Notice (ABN) Important Message from Medicare (IMM) Medicare Outpatient Observation Notice (MOON) and Condition Code 44 (CC44)

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

ONCALL*
*Note that employees may be required to be oncall during emergencies (ie. DIsaster Severe Weather Events etc) regardless of selection below.

• On Call* Yes

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area No

Houston Methodist West Hospital is committed to leading medicine in West Houston Katy and surrounding communities by delivering the Houston Methodist standard of exceptional safety quality personalized service and innovation. The growing campus offers more than 200 beds 19 operating rooms and over 1500 employees with access to the most innovative medical and surgical care available including robotic and minimally invasive surgery fullspectrum heart care stateoftheart imaging cancer care labor and delivery with a level II neonatal ICU neurology and neurosurgery orthopedics and sports medicine outpatient rehabilitation and 24/7 emergency services.