Utilization Review Specialist RN - FT Days

Overview

At Houston Methodist, the Utilization Review Specialist Nurse (URSN) 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. In addition to performing the duties of the URN, this position is able to cover a multitude of utilization review functions through point of entry, observation progression of care management, concurrent review and denials reviews. Additionally, the URSN will 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 URSN 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 pre-bill team members, as well as management. The URSN position helps drive change by identifying areas where performance improvement is needed (e.g., day-to-day workflow, education, process improvements).

Houston Methodist Standard

PATIENT AGE GROUP(S) AND POPULATION(S) SERVEDRefer 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 organization's vision, fulfills the mission and abides by the I CARE values

Responsibilities

PEOPLE ESSENTIAL FUNCTIONS

• Collaborates with the physician and all members of the interprofessional health care team to facilitate care and communication with payers, and external case managers. Intervenes, as necessary, to ensure the plan of care and services provided are patient-focused, high-quality, efficient, and cost-effective. Serves as a preceptor and implements staff education specific to patient populations and unit processes, coaches and mentors other staff and students.

• Serves as a resource for the department and hospital. Provides education to physicians, nurses, and other health care providers on utilization management topics.

• Initiates improvement of department scores for employee engagement, i.e. peer-to-peer accountability.

SERVICE ESSENTIAL FUNCTIONS

• Performs review for medical necessity of admission, continued stay, and resource use, appropriate level of care and program compliance. Identifies when services no longer meet evidence-based criteria, initiates discussions with attending physicians, coordinates with external utilization review teams to facilitate efficient use of resources and seeks assistance from the Physician Advisor when necessary. Informs management of the possible need for issuing Medical Hospital Issued Notices of Non-Coverage and Advance Beneficiary Notices of Non-Coverage.

• Applies approved utilization criteria to monitor appropriateness of admissions, level of care, resource utilization, and continued stay. Reviews level of care denials to identify trends and collaborates with team to recommend opportunities for process improvement.

• Promotes me