Under general supervision of the Director of Case Management, the Utilization Review Nurse provides a clinical review of cases using medical necessity criteria to determine the medical appropriateness of inpatient and outpatient services. Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. Provides ongoing communication with the health plan, clinical providers (HMH Physicians/NPs) and care coordination departments regarding medical necessity for prospective, concurrent, and retrospective reviews. Collaborates as a team to ensure that medical records support the level of services being delivered.
ESSENTIAL JOB FUNCTIONS
Every effort has been made to make this job description as complete as possible. However, it in no way states or implies that these are the only duties the incumbent will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.
LATITUDE, CONTACTS/INTERACTIONS
All positions of Huntsville Memorial Hospital are part of an interdisciplinary team, and as such, participate in the care and service delivery process through effective interaction with other team members. Primarily interacts with hospital staff, medical staff, patients, and visitors.
Requirements
Education: Graduate of a school of professional nursing or vocational nursing.
Experience: Two years of clinical nursing experience and utilization review experience preferred.
Licensure/Certification: Current licensure as a Registered Nurse or LVN in the state of Texas. Certification with the Fellowship of American Academy of Case Managers (FAACM) preferred.
Required Skills: Must have strong analytical, data management, organizational and time management skills. Must have knowledge of applicable federal and state regulatory requirements including: TDI, CMS, & HHSC.
PHYSICAL DEMANDS AND WORKING CONDITIONS
Frequent: sitting, standing, walking, & reaching.
Occasional: lifting, carrying, bending, & squatting,
Visual and hearing acuity required. Work is inside, with good ventilation and comfortable temperature.
Possible exposure to: toxic/caustic chemicals or detergents, communicable diseases, blood borne pathogens.
Benefits
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