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Utilization Review Nurse Jobs in Tom Green, Texas

Utilization Review Registered Nurse (Rn), Care Coordination, Full Time, Days
By MarinHealth Medical Center At , Greenbrae $66.03 - $99.04 an hour
Basic knowledge of government and private insurance benefits (e.g. Medi-Cal, Medicare, DRGs, and managed care), including reimbursement requirements is needed.
Experience in applying evidence based criteria related to utilization management.
Experience using case management software
National certification in Case Management preferred
Complies with all reporting requirements for mandated, risk management, and other medical/legal situations consistent with confidentiality policies and department standards.
Must be assertive and creative in problem solving, system planning and management.
Utilization Review Representative Jobs
By Ethos At Dallas, TX, United States
Receives, screens and manages mail, faxes and calls.
Collection and data entry of structured clinical data (including diagnosis, diagnosis codes, procedures, procedure codes).
Reviews service request for completeness of information.
Assigns reviews to Utilization Review Nurse
Assists with written determination letter communications via fax, e-mail or written mail under.
Maintains confidentiality and security in all aspects of performance.
Utilization Review Nurse Jobs
By Ethos At Austin, TX, United States
Certified Case Manager (CCM), Health Care Quality & Management (HCQM) or equivalent certification preferred.
1-year experience with workers' compensation/utilization management preferred.
Assists in promoting and furthering the objectives of the Quality Management Program.
Active, unrestricted professional license or certification to practice as a health professional in a state or territory of the United States:
2 years of clinical nursing experience (direct patient care, administrative or combination post licensure).
Knowledge of workers' compensation laws and regulations (preferred).
Medical Review Nurse - Entry Level
By Qlarant At Dallas, TX, United States
Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
Experience in ICD-9 coding, CPT coding, and knowledge of Medicare and/or Medicaid regulations.
Current RN license. An LVN will not meet the contract's requirements.
Employment history that shows progressively responsible experience.
Strong Medicare and/or Medicaid knowledge.
Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
Utilization Review Nurse Full Time – Care Management
By Montefiore Nyack Hospital At , Nyack, Ny

Description Comprehensively plans with the health care team to ensure patient needs are met and care delivery is coordinated across the continuum. Identifies and works to eliminate/minimize ...

Rn Utilization Review - Patient Access
By Penn State Health At , Enola, 17025, Pa
Communicates with the Medical Staff and Nursing Staff any utilization issues concerning patient care activities.
Presents Hospital Issued Notices of Non-coverage to patient/family and attending physician when patient's stay will no longer be covered by Medicare.
Acts as liaison between Hospital, physicians, patients and Medicare/Medicaid/Insurance review staff.
Performs preadmission and continued stay preauthorization for patients identified by Admissions as required this service.
Adheres to Federal and State rules as outlined.
Prepares monthly reports for review by the Medical Staff.
Utilization Review Specialist - Casual
By Nebraska Methodist Health System At , Omaha, 68118, Ne
Maintains knowledge of Payer requirements for peer to peer process, Skilled nursing facility authorization, & LTAC reviews.
Provides provider and care team ongoing education regarding utilization review/management.
Verifies authorization of services and communicates information to case management/nursing team.
Makes decisions based on evidence based practice, research, and UR nurse higher order critical thinking skills and experience.
Maintains knowledge of Payer requirements regarding length of stay for observation and transition to Inpatient
Documents actions taken and outcome(s) in Cerner Case Management tool, payer information.
Utilization Review Case Mgr-Cmc-Baybrook
By UTMB Health At , Galveston, 77555, Tx
Collaborates with care managers, providers, nursing and pharmacy to facilitate identified discharge needs and ensure services provided at destination infirmary.
Salary is commensurate with years of relevant work experience.
Monitors and facilitates appropriate utilization of resources and provides alternative options to hospital care (i.e., infirmary placement, urgent clinic).
Functions as a resource to physicians and nursing staff regarding approved criteria, specialty practice guidelines, and alternative treatment options.
Provides 24/7 access to care and care coordination through the telephone call center.
Adheres to internal controls established for department.
Utilization Review Specialist Jobs
By St. Charles Health System At , Bend, 97701, Or $24.32 - $33.44 an hour
Required: Associate's degree or higher in Health Information Management
Intermediate to advanced proficiency in Microsoft applications (Word, Excel and Access), database management, and document preparation
REPORTS TO POSITION: Manager, Utilization Review
Required: Minimum 2 years’ experience in similar hospital related position with utilization experience preferred
Strong team working and collaborative skills
Strong analytical, problem solving and decision making skills
Utilization Review Specialist Sr
By BayCare At , Riverview, Fl
Preferred experience includes Critical Care or Emergency Nursing RN.
Written and verbal communication skills
Knowledge of regulatory standards appropriate to position
Computer skills appropriate to position
Perform other duties as assigned by the supervisor including but not limited to processing concurrent denials.
401k match and additional yearly contribution
Utilization Review Specialist Jobs
By Medical Center Hospital At , Odessa, 79761, Tx

Holds a current Texas license as a Registered Nurse.

Registered Nurse Utilization Review Prn
By UT Southwestern At , Dallas, 75390, Tx

Registered Nurse Utilization Review PRN Days Remote Monday-Friday shifts Why UT Southwestern? With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, ...

Utilization Review Coordinator Jobs
By BENEFIT MARKETING ALLIES CORP. At , Austin, 78701, Tx

Position Description: ROLE AND RESPONSIBILITIES Communication with Providers regarding Pre-Authorization Requests. Provider Outreach Calls to retrieve Medical Records. Maintaining HIPAA Compliant ...

Utilization Management Nurse (South Central Region)
By Humana At , San Antonio, 78229, Tx
Utilization management experience which includes following MCG/Milliman or Interqual guidelines
Prior clinical experience preferably in an acute care, hospital, skilled or rehabilitation clinical setting
At least 3 years of varied clinical nursing experience
Comprehensive knowledge of Microsoft Word, Outlook and Excel
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Call center or triage experience
Utilization Review Nurse Jobs
By Methodist McKinney Hospital At , Mckinney, 75070, Tx
Uses knowledge of the nursing process and pathophysiology to interpret the needs or requirements of patients
Identifies, documents and communicates potential quality assurance or risk management issues as appropriate.
Uses knowledge of nursing process and pathophysiology to anticipate discharge needs.
Licensure as a registered nurse required.
Performs initial, concurrent, discharge and retrospective reviews.
Uses evidence-based medical guidelines to determine the medical appropriateness of inpatient and outpatient services
Concurrent Review Nurse Jobs
By University HealthCare Alliance At , Newark, 94560, Ca $49.59 - $65.71 an hour
Excellent communication, organizational and time management skills with the ability to meet tight timeframes.
Refer members to various other departments (i.e., Case Management, Disease Management, TPL, COB) for follow-up as appropriate.
Properly request letters, including applying the appropriate legal and regulatory requirements for ICE and health plan specific letter Templates.
All other duties as assigned including department-specific functions and responsibilities:
Three (3) years of Medical/Surgical clinical nursing experience.
Proficient in Microsoft Office applications and other computer skills.
Utilization Review Specialist Jobs
By Lexington Medical Center At , West Columbia, 29169, Sc
Communicates with case management triad regarding reimbursement issues.
We are committed to offering quality, cost-effective benefits choices for our employees and their families:
Manages inpatient Medicare discharge expedited appeals process through the QIO.
Indentifies abnormal patterns of utilization and refers to Manager/Director.
Day ONE medical, dental and life insurance benefits
Exhibits commitment and pride through personal example by positively speaking about LMC, the department, employees and guests.
Utilization Review Nurse Jobs
By INTEGRANET HEALTH At , Houston, Tx
Preferred knowledge in case management principles, utilization management procedures and practices
Prior experience with Utilization Management
Provides telephonic case management, referral of resources, education and other clinically based activities to plan member.
QUALIFICATIONS, SKILLS, ABILITIES AND PROFESSIONAL COMPETENCIES:
Experience with Health Plans and Managed Care
Previous training and demonstrated competence in negotiations, quality assurance and case management outcomes
Case Management Utilization Review Rn
By Steward Health Care At , Dallas, 75201, Tx
Collaborates with the multidisciplinary team to assist patient with benefits management.
Leadership skills required for role include effective mentoring, coaching, counseling, time management, problem solving, and strategic planning.
Experience (Type & Length): Three to five years of acute medical/surgical experience plus three to five years of Case Management experience.
Certification/Licensure: RN license required; Certification in Case Management (CCM) strongly preferred.
The Care Manager works collaboratively with all healthcare disciplines to assure appropriate and timely services.
Adaptability to change and good organizational skills required. Ability to read and communicate effectively in English.
Utilization Review Specialist Jobs
By Memorial Hermann Health System At , Houston, 77024, Tx
Experience / Knowledge / Skills
Refers cases and issues to Care Management Medical Director in compliance with Department procedures and follows up as indicated.
Effective oral and written communication skills.
Utilizes conflict resolution skills as necessary to ensure timely resolution of issues.
Uses appropriate criteria sets for admission reviews, continuing stay reviews, outlier reviews and clinical appropriateness recommendation.
Takes appropriate follow-up action when established criteria for utilization of services are not met.

Are you looking for a challenging and rewarding career as a Utilization Review Nurse? Join our team and help us make a difference in the lives of our patients! We offer competitive salaries, excellent benefits, and a supportive team environment. Come join us and make a positive impact on the healthcare industry!

Overview:

Utilization Review Nurses are responsible for ensuring that healthcare services are provided in a cost-effective and efficient manner. They review patient records to determine the appropriateness of care and services, and to ensure that they are in compliance with the standards of care. Utilization Review Nurses also provide education and support to healthcare providers and patients on the utilization of healthcare services.

Detailed Job Description:

Utilization Review Nurses are responsible for reviewing patient records to ensure that healthcare services are provided in a cost-effective and efficient manner. They analyze patient records to determine the appropriateness of care and services, and to ensure that they are in compliance with the standards of care. Utilization Review Nurses also provide education and support to healthcare providers and patients on the utilization of healthcare services. They may also be responsible for developing utilization review plans, monitoring utilization trends, and providing recommendations for improvement.

What is Utilization Review Nurse Job Skills Required?

• Knowledge of healthcare regulations and standards of care
• Ability to analyze patient records
• Excellent communication and interpersonal skills
• Ability to work independently and as part of a team
• Proficiency in computer applications
• Ability to work with a variety of healthcare providers

What is Utilization Review Nurse Job Qualifications?

• Bachelor’s degree in Nursing or related field
• Current Registered Nurse (RN) license
• Experience in utilization review or related field
• Knowledge of healthcare regulations and standards of care

What is Utilization Review Nurse Job Knowledge?

• Knowledge of healthcare regulations and standards of care
• Knowledge of medical terminology
• Knowledge of healthcare reimbursement systems
• Knowledge of healthcare quality improvement processes

What is Utilization Review Nurse Job Experience?

• Previous experience in utilization review or related field
• Previous experience in healthcare reimbursement
• Previous experience in healthcare quality improvement

What is Utilization Review Nurse Job Responsibilities?

• Review patient records to determine the appropriateness of care and services
• Monitor utilization trends and provide recommendations for improvement
• Develop utilization review plans
• Educate healthcare providers and patients on the utilization of healthcare services
• Ensure compliance with healthcare regulations and standards of care
• Maintain accurate and up-to-date records