To monitor adherence to the hospital’s utilization review plan to ensure the effective and efficient use of hospital services. Responsible for ensuring the appropriateness of hospital admissions and extended hospital stays. An understanding of the severity of an array of illnesses, intensity of service, and care coordination needs are the key, as the nurse must integrate clinical knowledge with billing knowledge to review, evaluate and arrange peer to peers when clinical denials related to medical necessity of the patient while hospitalized. UM nurse will work closely in collaboration with physician advisers to support policy development, and process improvement.
Required Skills
- Two years prior experience with Utilization Management.
- Previous training and demonstrated competence in negotiations, quality assurance, case management outcomes, and keyboarding/computer use.
- Experience with InterQual and/or Milliman Care Guidelines preferred. Strong organizational and time management skills.
- Ability to work on extremely complex problems where analysis of situations or data requires an evaluation of intangible variance factors
Required Experience
Work Experience:
- Two years prior experience with Utilization Management.
- Previous training and demonstrated competence in negotiations, quality assurance, case management outcomes, and keyboarding/computer use.
- Experience with InterQual and/or Milliman Care Guidelines. Strong organizational and time management skills.
- Ability to work on extremely complex problems where analysis of situation or data requires an evaluation of intangible variance factors.
License/Registration/Certification:
- Current RN License to practice in the State of Texas.
Education and Training:
- Associate’s Degree in Nursing, BSN preferred.