CLINICAL REVIEW RN UM PRN

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Location:
Arlington, TX US
Job ID:
100076
Area of Interest:
RN
Job Type:
PRN
Facility:
Texas Health Resources System Services


Qualifications/Duties:
Why Texas Health Resources?

Our facilities are located across the greater Dallas – Ft. Worth area with a centrally located corporate office in Arlington, TX. We are one of the largest faith-based, nonprofit health care delivery systems in the US that has the resources to offer a variety of career growth and professional development opportunities with equally remarkable benefits. Join our award-winning Texas Health family and contribute to our mission “to improve the health of the people in the communities we serve”. A few recent accomplishments we achieved include:
• 2018 FORTUNE Magazine’s “100 Best Companies to Work For®” (4th year in a row)
• 2015 “Healthiest Employer in North Texas” by Dallas Business Journal and 2015 Fortune “100 Best Workplaces for Millennials”
• Ranked #1 on the Fortune’s 2015 and 2016 “20 Best Workplaces in Health Care” and #2 on the nation's 50 Best Workplaces for Diversity for 2015 by Great Place to Work®
• 2015, 2016 and 2017 Platinum-level recognition from the American Heart Association (AHA) for being a “Fit-Friendly Worksite”
• 2015 Great Place to Work® and Fortune list of “50 Best Workplaces for Camaraderie”
• 2017 Becker's Healthcare "150 Great Places to Work in Healthcare" (3rd year in a row)
• Named by Hospital & Health Networks magazine as one of the nation’s 2016 “Most Wired” health care systems for the 16th time in 18 years
• Ranked #1 on 2016 and 2017 “100 Best Workplaces for Women list” by Great Place to Work®
• Platinum-level recognition in the 2016 and 2017 Best Employers for Healthy Lifestyles® awards, sponsored by the National Business Group on Health (ninth year to appear on the list and second year to receive the Platinum award
• Stage 7 Revalidation~ Texas Health Resources recently earned revalidation recognition for the premier award for electronic health record (EHR) adoption
Largest Blue Zones® Project Approved™ Worksite in the world (2016)


Texas Health

PRN, some weekends required. 8:00am to 4:30pm

Required Minimum Experience:
Associate's Degree in Nursing required.
Bachelor's Degree in Nursing preferred.

Required Minimum Experience:
5 years of inpatient clinical nursing experience in an acute hospital setting and 1 year of utilization management required. Experience in case management, and / or the application of medical necessity criteria preferred.

Skills and Abilities:
Requires interpersonal, analytic, and critical thinking skills for problem solving and decision making. Broad and intimate knowledge of reimbursement and regulatory requirements. Decisive judgment and the ability to work with minimal supervision.
Must be able to work in a fast-paced environment requiring adaptability, flexibility, and independence while demonstrating high professional standard, leadership, and team membership skills. Must be well organized and have the ability to prioritize and
handle multiple tasks efficiently and independently. Have demonstrated ability to initiate and follow through with multiple projects. Proficient computer skills with experience in: MS Office, internet navigation, clinically-based software, and financially-based software.

Required License / Certifications:
Current Registered Nurse (RN) license to practice professional nursing in the state of Texas required. Specialty certification preferred.

Essential Functions:
• Responsible for determining initial admission status and level of care recommendations for inpatient admissions, observation and outpatient admissions for any hospital in the THR system (requires access to all facilities in Care Connect)
• Conduct initial admission review of inpatient, observation and outpatient admissions (commercial insurance, Medicare Advantage and self-pay) according to established criteria set adopted by System. Conduct initial admission review of inpatient, observation and outpatient admissions with traditional Medicare for compliance with the New IPPS rule.
• Provide clinical information to payors as needed for completion of pre-certification process.
• Ensure proper authorization requirements are met with each admission. Obtains or ensures acquisition of appropriate pre-certifications/authorizations from third party payers and placement to appropriate level of care prior to hospitalization or upon admission utilizing medical necessity criteria and third party payer guidelines.
• Obtains, or facilitates, acquisition of urgent/emergent authorizations, continued stay authorizations, as needed and with compliance with all regulatory and contractual requirements.
• Maintains a working knowledge of care management, utilization review changes, authorization changes, contract changes, regulatory requirements, etc.
• Adheres to the policies, procedures, rules, regulations, and laws of the hospital and federal and state regulatory bodies.
• Communicates and collaborates with the CBO and medical records to render appropriate information needed to secure reimbursement.
• Provide consultation to medical and nursing staff, health information management, and payors on potential issues with reimbursement of hospitalization.
• Evaluate concurrent potential denials or payment issues and initiate communication with admitting physician to assure proper documentation for selected admission status.
• Collaborates and communicates with payor via phone, fax or computer system per payor contract.
• Initiates and facilitates physician communications relative to the UR process when indicated. Assists and facilitates the physician peer-to-peer review process with insurance medical directors as indicated.
• Communicates payer issues and medical necessity concerns with members of the health care team.
• Escalate incorrect status concerns to UM manager.
• Determines working DRG with each initial review via Canopy, or other Care Management tool. Discusses working DRG issues as needed with Care Transition Manager.


Entity Information:
Texas Health Resources is one of the largest faith-based, nonprofit health care delivery systems in the United States and the largest in North Texas in terms of patients served.
Texas Health has 25 acute-care and short-stay hospitals that are owned, operated, joint-ventured or affiliated with the system. It has more than 3,800 licensed beds, more than 21,100 employees of fully-owned/operated facilities plus 1,400 employees of consolidated joint ventures, and counts more than 5,500 physicians with active staff privileges at its hospitals.
At Texas Health, we strive to create an atmosphere of respect, integrity, compassion and excellence for all who come in contact with us, be they patients or our employees. We are committed to diversity in our workforce, and our mission to serve spreads across ethnic, cultural, economic and generational boundaries.  We invite you to join us in furthering your career through our accomplishments and philosophy of excellence.
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