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Utilization Review Nurse (LVN)

Partnership Market Office - Austin, Texas

Job Code: PARTN-2018

Full-time

No Weekends

With more than 119 sites across Central Texas, St. David’s HealthCare includes seven of the area’s leading hospitals and is one of the largest health systems in Texas. The organization has been recognized with a Malcolm Baldrige National Quality Award — the nation’s highest presidential honor for performance excellence. St. David’s HealthCare is the third-largest private employer in the Austin area, with more than 10,200 employees.

 

St. David’s HealthCare is a unique partnership between a hospital management company and two local non-profits—St. David’s Foundation and Georgetown Health Foundation. The proceeds from the operations of the hospitals fund the foundations, which, in turn, invest those dollars back into the community. Since the inception of St. David’s HealthCare in 1996, more than $425 million has been given back to the community to improve the health and healthcare of Central Texans.


POSITION SUMMARY
The Utilization Review Nurse (URN) functions as the primary liaison between all managed care payers and the Case Management department.  The URN is responsible for communicating required clinical information for the purpose of obtaining certification and approval for payment for all applicable outpatient observation stays, inpatient admissions and continued stay days.  The URN will communicate and document all payer contacts using the established Case Management process.  The URN works collaboratively with all payers, as well as, Case Management staff, Physician Advisor(s), physicians, healthcare team members, Patient Access Department, Central Verification Office and other key departments regarding the payer certification process to ensure authorization is received for all services provided. 
 
ESSENTIAL JOB RESPONSIBILITIES
  • Serves as the primary contact for all payors regarding utilization review and management issues.
  • Performs concurrent payor reviews for medical appropriateness for patients placed in outpatient observation or in an inpatient setting according to payor guidelines, rules and regulations.
  • Provides all required clinical information to the payor according to the payor's timeframe standards throughout the hospitalization to obtain certification approval for all services provided.
  • Maintains a collaborative working relationship with the payor's utilization review nurses and case managers and maintains contact with the payor regarding initial assessment, progress, changes in condition, discharge planning, discharge date, etc. as needed.
  • Refers all cases that are denied by the payor to the Concurrent Appeal URN or Physician Advisor.
  • Establishes and maintains professional, collaborative working relationships with the Business Office Registration Department, Revenue Cycle Department and other key departments to facilitate processes to ensure timely and appropriate reimbursement for services provided.
  • Maintains productivity and meets all UR performance standards according to department policies and procedures.
  • Participates in process performance improvement activities related to utilization management.
  • Attends education sessions each year for internal and external customers regarding utilization management.

QUALIFICATIONS (REQUIRED)
  • LVN with current state licensure 
  • Two years of experience in case management, utilization management or related field
  • Certification in Case Management, Nursing, or Utilization Review preferred
  • Acute care hospital experience, preferred
  • Knowledge of InterQual or related evidenced based criteria sets
  • Familiar with Joint Commission, State and Federal standards/requirements.
  • Knowledgeable about third party payer source criteria of medical necessity.
  • Organized and able to meet deadlines consistently.
  • Computer experience required with skills including but not limited to Microsoft Windows, spreadsheets, and word processing.
EXPERIENCE
Required: Two years of experience in case management, utilization management or related field
 
LICENSE/CERTIFICATION
Required: Current LVN license in the state of Texas or compact state

Technical Diploma

Last Edited: 01/08/2019

 

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