Sr Utilization Review Specialist Nurse

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

• Promotes a positive work environment and leads the team to be a dynamic team-focused work unit that actively helps one another to achieve optimal department results. Acts as a role model to team members exemplifying effective communication skills. Collaborates with all members of the patient care team by actively communicating and reporting pertinent utilization information and data in a comprehensive manner.

• Works with physician leadership and the interprofessional health care team for defined patient populations to develop clinical pathways and measurement and feedback of performance indicators for cost quality and service and patient satisfaction. Collaborates with the Physician Advisor to address identified educational needs for providers and utilization review/case management team members.

• Serves as the primary information resource for utilization management staff payers physicians and other health care team members and customers. Acts as a formal preceptor/coach for new utilization review employees. Develops skills of team members and continually assists with improving skills performance and outcomes. Provides feedback to management on team member performance and conduct.

• Collaborates with leadership team on recruitment and retention strategies and key initiatives to improve employee relations participation and engagement i.e. peer-to-peer accountability.

• Serves as a leader for comprehensive utilization review activities including reviewing for 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 leads resolution of barriers to efficient patient throughput.

• Continuously reviews the total picture of the patient for opportunities for care facilitation. Mentors others regarding appropriate utilization review and appropriate utilization and levels of care.

• Independently handles resolution of complex problems and issues. Serves as an escalation support for novice staff. Implements and leads to initiatives to improve documentation accuracy that reflects intensity of services quality and safety indicators and patients need to continue stay.

• Proactively takes action to achieve continuous improvement and expedite care/facilitate discharge. Promotes use of evidence-based protocols and/or order sets to influence high quality and cost-effective care.

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

• Conducts chart audits and performs peer-to-peer evaluations for continuous quality improvement.

• Takes leadership role in collaborating with employees to secure reimbursement for hospital services. Collaborates with department leadership on cost-reduction strategies. Leads efforts to ensure appropriate capture of avoidable and excess days. Reports trends to department leadership team.

• Functions as a resource to department staff in communicating medical information required by external review entities managed care contractors insurers fiscal intermediaries state and federal agencies. Collaborates with the appropriate resources to mitigate denials.

• Collaborates with department leadership and revenue cycle partners regarding any claim issues or concern that may require clinical review during the pre-bill audit or appeal process.

• Expands own knowledge and serves as an instructor in continuing education or formal program and expert consultation; coaches staff to grow in knowledge abilities skills and attitudes. Reads and leads critique of evidence-based practice literature in case management and utilization management and related disciplines. Identifies plans and implements education for the service line in collaboration with team members and interprofessional partners.

• Fulfills role of leadership on at least one hospital or system-wide committee. Seeks opportunities to identify self-development needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an ongoing basis.

• Bachelors degree or higher from an accredited school of nursing

• Masters degree preferred

• Seven years of hospital clinical nursing experience which includes five years in case management

• RN - Registered Nurse - Texas State Licensure -- Compact Licensure - Must obtain permanent Texas license within 60 days (if establishing Texas residency) AND
• Magnet ANCC-recognized Case Managment certification: ACHPN-HPCC or CCM or CMC or ACM-NBCM or CDCES or CHPN-HPCC or CMGT-BC or CM-ABOHN or CMCN or ANCC-NCM

• Demonstrates the skills and competencies necessary to safely perform the assigned job determined through on-going 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 co-workers in a manner consistent with a customer service focus and application of positive language principles

• Ability to effectively communicate with physicians colleagues and payer representatives in a manner consistent with a customer service focus and application of positive language principles

• Knowledge of Medicare Medicaid and Managed Care requirements

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

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

• Skill-specific areas include regulatory requirements pathway development/ implementation ethics/healthcare law etc.

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

• Strong assessment organizational and problem-solving skills as evidenced by capacity to prioritize multiple tasks and role components

• Proficient in computer skills of the entire Microsoft Office Suite (Access Excel Outlook PowerPoint and Word)

• Expert knowledge of federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) Ambulatory Benefit Notice (ABN) Important Message from Medicare (IMM) Medicare Outpatient Observation Notice (MOON) and Condition Code 44 (CC44)

• Required passage of Interrater Reliability test (IRR)

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

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

ON-CALL*
*Note that employees may be required to be on-call 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

Since its founding in 1919 Houston Methodist Hospital has earned worldwide recognition. Houston Methodist Hospital is affiliated with the Weill Medical College of Cornell University and New York-Presbyterian Hospital one of the nations leading centers for medical education and 2020 U.S. News & World ReportnamedHouston Methodist Hospitalto its top ranked Honor Roll for the fourth time and second consecutive year. 2020 also marked the ninth year in a row Houston Methodist Hospital has been named the No. 1 hospital in Texas. Houston Methodist Hospital directs millions of research dollars into patient care and offers the latest innovations in medical surgical and diagnostic techniques. With 952 operating beds 85 operating rooms and over 8000 employees Houston Methodist offers complete care for patients from around the world.

The same high-quality care for which Houston Methodist is known is available at several Emergency Care Centers in Houston and the surrounding areas. These Emergency Care Centers house exam rooms full digital radiography suite low radiation dose 16-slice CT scan ultrasound and a full on-site stat chemistry lab.