Utilization Management Nurse - Pchp

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

PRIMARY PURPOSE Parkland Community Health Plan's (PCHP's) Utilization Management (UM) Nurse is responsible for the management of members requiring care for continued services such as hospitalizations including discharge planning and transitions of care. Oversees the application of clinical guidelines in determining appropriateness of requested and continued healthcare services. Ensures that all clinical decisions are completed according to evidence based best practice guidelines and meets regulatory requirements. Seeks Medical Director input for review of cases not meeting criteria and monitors time frames for decision making and notifications of decision.

MINIMUM SPECIFICATIONS

Education

Experience

Equivalent Education and/or Experience

Certification/Registration/Licensure

Skills or Special Abilities

- Proficient in Microsoft Word, Excel and Power Point. - Competent in UM functions including application of InterQual criteria.

Responsibilities

Job Accountabilities

1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.

2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.

3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. As part of our commitment to our patients and employees’ wellness, Parkland Health is a tobacco and smoke-free campus.