The mission of The University of Texas MD Anderson Cancer Center is to eliminate cancer in Texas, the nation, and the world through outstanding programs that integrate patient care, research and prevention, and through education for undergraduate and graduate students, trainees, professionals, employees and the public.The primary purpose of the Utilization Review Nurse position is to:Evaluate the necessity, appropriateness, and efficient use of medical services, procedures and setting in which the patient receives careEnsure appropriate payment of services that includes review of the appropriate patient class, providing clinical reviews to payers utilizing specified guidelines, and facilitate timely peer to peer or appeals to mitigate denialsKEY FUNCTIONSStandards of Practice ₠" Utilization Review ConceptsApplies approved clinical criteria and payer related guidelines to monitor appropriateness of admission, continued stays and level of care and documents findings according to departmental guidelinesUtilizes clinical knowledge and experience to abstract key information from the medical record and provides a clear understanding of the need for current bed statusDemonstrates ability to work independently and exercise sound judgment in interactions with physicians, members of the interdisciplinary team, internal and external customers, patients and their familiesDemonstrates excellent interpersonal communication and negotiation skillsDemonstrates strong organizational and time management skills as evidenced by ability to prioritize and manage multiple tasks and role componentsUtilization Review ActivitiesEnsures the admission order is accurate and correlates with the displayed patient classCollaborates and communicates with the Case Manager on payer related issues that may impact the patient₠™s continuity of care (such as being out of network or underfunded)Discusses patient status with medical team when order or documentation does not support the patient classDocuments all correspondence with payer and medical team according to department guidelinesPerforms and documents utilization reviews according to established Departmental Utilization Review GuidelinesMonitors patients in Observation & Extended Recovery status and initiates appropriate actionsInterface with payor to provide clinical information as required to support medical necessity for servicesEnsures utilization review case closures are completed within 4 business days post dischargeServes as an expert resource and support to onsite review nurses and Utilization Review SpecialistCompletes level of care (LOC) assessments on all assigned patients and identifies all avoidable days/delays as appropriate.Performs necessary interventions to prevent denials, as appropriateFacilitates peer to peer review related to denials for failure to meet acute care criteria within one business day from notificationFollows up with next level of appeal within 5 business days and escalates as appropriateMaintains working knowledge of applicable payer-based rules for bed status determination and changes (such as Condition Code 44 and Medicare Inpatient only List)Attends all mandatory departmental staff and team meetings and training sessionsAssigns role as Utilization Review Nurse in EPICDiscuss payor criteria and concerns in a timely manner with the physician and interdisciplinary team to resolve issues/concerns with payorsIdentifies self-pay patients and follows up to ensure if actual self-pay, refer to Patient Access Center for financial assessment.Completes ACMA Compass training annuallyDocumentationReconciles patient days, next review dates and authorizations in EPICIncludes appropriate chemo related medications, code and indications for use in clinicalsDocuments daily Utilization Review activities appropriately in EPIC to reflect correspondence prior to the close of the business dayUtilizes sticky notes and handoff tools to communicate with medical teamActivates out of office notification on e-mail and voice mail with appropriate information prior to scheduled day offDemonstrates compliance with all state and federal regulatory requirementsFacilitates authorizations for transfers back from Rehab to an acute care bedOther duties as assignedEducation Required: Associate's degree in nursing (ADN).Experience Required: Three years of experience as a Registered Nurse.Licensure Required: Current State of Texas Professional Nursing License (RN). American Heart Association (AHA) Basic Life Support (BLS)It is the policy of The University of Texas MD Anderson Cancer Center to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, disability, protected veteran status, genetic information, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. http://www.mdanderson.org/about-us/legal-and-policy/legal-statements/eeo-affirmative-action.htmlAdditional Information
Requisition ID: 174043
Employment Status: Full-Time
Employee Status: Regular
Work Week: Day/Evening
Minimum Salary: US Dollar (USD) 89,000
Midpoint Salary: US Dollar (USD) 111,000
Maximum Salary : US Dollar (USD) 133,000
FLSA: exempt and eligible for overtime, paid at a straight rate
Fund Type: Hard
Work Location: Hybrid Onsite/Remote
Pivotal Position: No
Referral Bonus Available?: No
Relocation Assistance Available?: No
Science Jobs: No
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