Job Description
MISSION STATEMENT
The mission of The University of Texas M. D. 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.
SUMMARY
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 care
• Ensure 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 denials
KEY FUNCTIONS
Standards of Practice
Utilization Review Concepts
• Applies approved clinical criteria and payer related guidelines to monitor appropriateness of admission, continued stays and level of care and documents findings according to departmental guidelines
• Utilizes clinical knowledge and experience to abstract key information from the medical record and provides a clear understanding of the need for current bed status
• Demonstrates ability to work independently and exercise sound judgment in interactions with physicians, members of the interdisciplinary team, internal and external customers, patients and their families
• Demonstrates excellent interpersonal communication and negotiation skills
• Demonstrates strong organizational and time management skills as evidenced by ability to prioritize and manage multiple tasks and role components
Utilization Review Activities
• Ensures the admission order is accurate and correlates with the displayed patient class
• Collaborates 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 class
• Documents all correspondence with payer and medical team according to department guidelines
• Performs and documents utilization reviews according to established Departmental Utilization Review Guidelines
• Monitors patients in Observation & Extended Recovery status and initiates appropriate actions
• Interface with payor to provide clinical information as required to support medical necessity for services
• Ensures utilization review case closures are completed within 4 business days post discharge
• Serves as an expert resource and support to onsite review nurses and Utilization Review Specialist
• Completes level of care (LOC) assessments on all assigned patients and identifies all avoidable days/delays as appropriate.
• Performs necessary interventions to prevent denials, as appropriate
• Facilitates peer to peer review related to denials for failure to meet acute care criteria within one business day from notification
• Follows up with next level of appeal within 5 business days and escalates as appropriate
• Maintains 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 sessions
• Assigns role as Utilization Review Nurse in EPIC
• Discuss payor criteria and concerns in a timely manner with the physician and interdisciplinary team to resolve issues/concerns with payors
• Identifies self-pay patients and follows up to ensure if actual self-pay, refer to Patient Access Center for financial assessment.
• Completes ACMA Compass training annually
Documentation
• Reconciles patients' days, next review dates and authorizations in EPIC
• Includes appropriate chemo related medications, code and indications for use in clinicals
• Documents daily Utilization Review activities appropriately in EPIC to reflect correspondence prior to the close of the business day
• Utilizes sticky notes and handoff tools to communicate with medical team
• Activates out of office notification on e-mail and voice mail with appropriate information prior to scheduled day off
• Demonstrates compliance with all state and federal regulatory requirements
• Facilitates authorizations for transfers back from Rehab to an acute care bed
Other duties as assigned
Associate's degree in nursing (ADN). Three years of experience as a Registered Nurse. 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.
Additional Information
- Requisition ID: 169972
- Employment Status: Full-Time
- Employee Status: Regular
- Work Week: Day/Evening
- Minimum Salary: US Dollar (USD) 86,000
- Midpoint Salary: US Dollar (USD) 107,500
- Maximum Salary : US Dollar (USD) 129,000
- FLSA: exempt and eligible for overtime, paid at a straight rate
- Fund Type: Hard
- Work Location: Onsite
- Pivotal Position: Yes
- Referral Bonus Available?: Yes
- Relocation Assistance Available?: Yes
- Science Jobs: No
#LI-Onsite
Job Tags
Full time, Traineeship, Local area, Relocation package, Afternoon shift,