Utilization Management (UM) Reviewer RN - Utilization Management, SWHR at Southwestern Health Resources CIN in Pittston, Pennsylvania

Job Description:

******SIGN ON BONUS OF $2,500********

Utilization Management Reviewer RN

Utilization Management

Southwestern Health Resources, a national leader in population health, is looking for a qualified Utilization Management Reviewer RN to join our Utilization Management team.

If you're looking for a rewarding career at a patient-centered organization with work-life balance and comprehensive benefits, we want to hear from you.

Position Highlights

Work location: Southwestern Health Resources Headquarters, 1603 Lyndon B. Johnson Freeway, Farmers Branch, TX 75234

Work environment: Utilization Management Department.

Please note: The Utilization Management Reviewer RN will be an employee of Southwestern Health Resources (SWHR). SWHR is a clinically integrated network formed by Texas Health Resources and University of Texas Southwestern Medical Center.

Work hours:

• Full-Time, 40 hours per week.
• Tuesday - Saturday, 8:00am - 5:00pm.
• Occasional weekend on-call on a rotational basis.
• Must work at least one major holiday per year.
• This is a telework position, however, may require onsite workdays during the week, based on department business needs.
• May require in-person attendance as needed, to department meetings, trainings and/or other department authorized activities, at the above-mentioned address or other locations as directed by the department management.
• $2,500 sign-on bonus for eligible RN's (eligible upon hire with a signed retention agreement)

Southwestern Health Resources (SWHR) is a patient-centered clinically integrated network of 29 hospital locations and more than 5,500 physicians and other clinicians. Formed by Texas Health Resources and University of Texas Southwestern Medical Center, two of the region's leading healthcare systems, SWHR delivers nationally preeminent, highest-quality care in 16 counties across North Texas.

The SWHR Network includes physicians from University of Texas Southwestern Medical Center and Texas Health Resources, as well as more than 2500 independent community Primary and Specialty Care Physicians. In partnership, our team implements physician-driven, value-based care strategies to coordinate care for more than 700,000 patients, across 16 counties in North Texas, resulting in lower costs and high-quality care.

In 2020, the Centers for Medicare & Medicaid Services (CMS) released the annual financial and quality results. Based on the report, SWHR is one of the nation's leading Next Generation Accountable Care Organizations (ACO), having saved nearly $120 million since joining the program in 2017.

SWHR is the parent organization of Care N' Care Insurance Co., a leading regional Medicare Advantage health plan organization that serves approximately 17,000 patients in North Texas.

Education

• Associate's degree in Nursing required.

OR,

• Bachelor's degree in Nursing or Master's degree in Nursing preferred.

Licenses & Certifications

• Current and active Registered Nurse (RN) License upon hire required.

Experience

• Require 3 years of Utilization Management experience in an acute or post-acute provider, health plan or other care company.
• Require 2 years of direct patient care experience as an RN, in an acute care setting, especially in ER, ICU, or Medical/ Surgical unit.
• Prefer 5 years of experience in Health Plan Utilization Review, Discharge Planning and Medical Case Management.
• Highly prefer experience in handling Outpatient and Home Health cases.
• Prefer 1 year of Prior Authorization or Home Health experience.

Skills & Abilities

• Experience and knowledge of Milliman Guidelines or similar clinical guidelines preferred.
• Strong analytical and organizational skills.
• Working knowledge and ability to apply professional standards of practice in work environment.
• Knowledge of specific regulatory, managed care requirements, and strong attention to detail.
• Working knowledge of computers and basic software applications used in job functions such as word processing, graphics, databases, spreadsheets, etc.

Position Responsibilities

Utilization Management (UM) Reviewer RN will be accountable for performing initial, concurrent, or post service review activities; discharge care coordination; and assisting with efficiency and quality assurance of medical necessity reviews in alignment with Federal, State, Plan, and Accreditation standards. The UM reviewer serves as a liaison between providers/ facilities and Care Management Division.

Position Functions

• Supports the Collaborative Care Management Model as a working partner with physicians, social workers, pharmacists and other professional staff.
• Accurately applies decision support criteria.
• Demonstrates proficiency with caseload assignment and ability to manage complex cases effectively.
• Demonstrates an understanding of funding resources, services and clinical standards and outcomes.
• Demonstrates knowledge of case management standards of practice and processes including identification and assessment, planning, interventions and evaluation.
• Demonstrates a solid understanding of managed care trends, Medicare, and Medicaid regulations, reimbursement and the effect on utilization and outcomes of the different methods of reimbursement.
• Demonstrates the ability to develop departmental interfaces with internal and external customers to provide exemplary service and achieve goals.
• Demonstrates participation in multi-disciplinary team rounds if designated to cover a facility designed to address utilization/resource and progression of care issues. Assists in developing and implement an improvement plan to address issues.
• Implement discharge plan to prevent avoidable days or delays in discharge.
• Transition patient to next level of care in coordination with facility Discharge Planner.
• Identify and refer complex risk members to case management.
• Complete documentation timely, completely, and accurately in accordance with: (a) eligibility and benefits (b) clinical guidelines/criteria (c) legal and regulatory requirements.
• Identify documents and refer cases to the UM Team Leader for medical review when services do not meet medical necessity criteria, and/or appropriate level of care, and/or potential quality issues.
• Maintains objectivity in decision making, utilizing facts to support decisions.
• Supports the mission statement, policies and procedures of the organization.
• Assists in eliminating boundaries to achieve integrated, efficient and quality service.
• Achieves ongoing compliance with all regulatory agencies.
• Serves as a resource to employees and customers as demonstrated by visibility and knowledge of issues.
• Reviews and adheres to department policies and the Utilization Management Plan and Case Management program specific requirements.
• Completes interdepartmental education.
• Utilizes resources efficiently and effectively.
• Maintains safe environment.
• Participates in Performance Improvement activities.

Why Southwestern Health Resources

As a Southwestern Health Resources employee, you'll enjoy, comprehensive benefits, including a 401(k) with match; paid time off; competitive health insurance choices; healthcare and dependent care spending account options; wellness programs to keep you and your family healthy; tuition reimbursement; a student loan repayment program; and more.

Additional perks of being an SWHR employee:

• Gain a sense of accomplishment by contributing to a teamwork environment.
• Positively impact patients' quality of life.
• Receive excellent mentorship, comprehensive training and dedicated clinical and administrative leadership resources.
• Enjoy opportunities for growth.

Explore Southwestern Health Resources Careers for more information and to search all career opportunities.

Our Recruitment team invites you to contact us with any questions at recruitment@texashealth.org.

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