Senior Utilization Review Specialist Nurse

At Houston Methodist, the Sr Utilization Review Specialist Nurse (URSN) position is a licensed registered nurse (RN) responsible for promoting the achievement of optimal clinical and resource outcomes, accountable for a designated assignment that is considered more complex and resource intensive. This position has achieved an expert level at all objectives delineated in the Utilization Review Nurse and Utilization Review Specialist Nurse job roles, assumes leadership responsibilities with high-level contributions in financial stewardship within the organization and is responsible for facilitating appropriate length of stay (LOS) and reimbursement for all hospital admissions in accordance with set goals and objectives. The Sr URSN position assures that admission and continued stay are medically necessary, communicating clinical information to payers to ensure reimbursement, serving as a clinical resource for both service line program and hospital staff as well as evaluation of direct costs and patient outcomes. This position analyzes variances to identify opportunities for improvement and acts as the key information and education resource for the interprofessional health care team including leading department/system activities, mentoring, educating, and coaching staff with the expectation to collaborate/manage/lead department/system/national initiatives. The Sr URSN position works with the leadership team for special project activities related but not limited to, throughput, utilization review and utilization management to align with the visions and goals of the department and organization. This position will perform specialized responsibilities including assisting management with the coordination of program education and the overall growth of the department as well as providing staff guidance in the absence of leadership, as necessary, as a regular part of their normal job responsibilities. Responsibilities for the Senior URSN position may also include leading unit and shared governance activities, assessing service line/unit-based needs related to practice and improvement opportunities.

FLSA STATUS
Exempt

QUALIFICATIONS

EDUCATION

• Bachelor’s degree or higher from an accredited school of Nursing
• Master’s degree preferred

EXPERIENCE

• Seven years of hospital clinical nursing experience, which includes five years in utilization review and/or case management

LICENSES AND CERTIFICATIONS
Required

• RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency) and
• Magnet ANCC-recognized Case Management certification: ACHPN-HPCC or CCM or CMC or ACM-NBCM or CDCES or CHPN-HPCC or CMGT-BC or CM-ABOHN or CMCN or ANCC-NCM

SKILLS AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations
• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
• Ability to effectively communicate with physicians, colleagues, and payer representatives in a manner consistent with a customer service focus and application of positive language principles
• Knowledge of Medicare, Medicaid, and Managed Care requirements
• Knowledge of community resources, health care financial and payer requirements/issues, and eligibility for state, local, and federal programs
• Expert knowledge of utilization management, case management, performance improvement, and managed care reimbursement
• Skill-specific areas include regulatory requirements, pathway development/ implementation, ethics/healthcare law, etc.
• Ability to work independently and exercise sound judgment in interactions with physicians, payers, and health care team members
• Strong assessment, organizational, and problem-solving skills as evidenced by capacity to prioritize multiple tasks and role components
• Proficient in computer skills of the entire Microsoft Office Suite (Access, Excel, Outlook, PowerPoint, and Word)
• Expert knowledge of federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44)
• Required passage of Interrater Reliability test (IRR)

ESSENTIAL FUNCTIONS

PEOPLE ESSENTIAL FUNCTIONS

• Promotes a positive work environment and leads the team to be a dynamic, team-focused work unit that actively helps one another to achieve optimal department results. Acts as a role model to team members exemplifying effective communication skills. Collaborates with all members of the patient care team by actively communicating and reporting pertinent utilization information and data in a comprehensive manner.
• Works with physician leadership and the interprofessional health care team for defined patient populations to develop clinical pathways and measurement and feedback of performance indicators for cost, quality, and service and patient satisfaction. Collaborates with the Physician Advisor to address identified educational needs for providers and utilization review/case management team members.
• Serves as the primary information resource for utilization management staff, payers, physicians, and other health care team members and customers. Acts as a formal preceptor/coach for new utilization review employees. Develops skills of team members and continually assists with improving skills, performance, and outcomes. Provides feedback to management on team member performance and conduct.
• Collaborates with leadership team on recruitment and retention strategies and key initiatives to improve employee relations, participation, and engagement, i.e., peer-to-peer accountability.

SERVICE ESSENTIAL FUNCTIONS

• Serves as a leader for comprehensive utilization review activities including reviewing for appropriateness of the treatment plan relative to the patient’s preference, reason for admission, and availability of resources. Participates in daily Care Coordination Rounds and identifies and leads resolution of barriers to efficient patient throughput.
• Continuously reviews the total picture of the patient for opportunities for care facilitation. Mentors others regarding appropriate utilization review and appropriate utilization and levels of care.
• Independently handles resolution of complex problems and issues. Serves as an escalation support for novice staff. Implements and leads to initiatives to improve documentation accuracy that reflects intensity of services, quality and safety indicators and patient’s need to continue stay.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Proactively takes action to achieve continuous improvement and expedite care/facilitate discharge. Promotes use of evidence-based protocols and/or order sets to influence high quality and cost-effective care.
• Identifies and records episodes of preventable delays or avoidable days due to failure of the progression of care process.
• Conducts chart audits and performs peer-to-peer evaluations for continuous quality improvement.

FINANCE ESSENTIAL FUNCTIONS

• Takes leadership role in collaborating with employees to secure reimbursement for hospital services. Collaborates with department leadership on cost-reduction strategies. Leads efforts to ensure appropriate capture of avoidable and excess days. Reports trends to department leadership team.
• Functions as a resource to department staff in communicating medical information required by external review entities, managed care contractors, insurers, fiscal intermediaries, state, and federal agencies. Collaborates with the appropriate resources to mitigate denials.
• Collaborates with department leadership and revenue cycle partners regarding any claim issues or concern that may require clinical review during the pre-bill, audit, or appeal process.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Expands own knowledge and serves as an instructor in continuing education or formal program and expert consultation; coaches staff to grow in knowledge, abilities, skills, and attitudes. Reads and leads critique of evidence-based practice literature in case management and utilization management and related disciplines. Identifies, plans, and implements education for the service line in collaboration with team members and interprofessional partners.
• Fulfills role of leadership on at least one hospital or system-wide committee. Seeks opportunities to identify self-development needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an ongoing basis.

SUPPLEMENTAL REQUIREMENTS
WORK ATTIRE

• Uniform: No
• Scrubs: No
• Business professional: Yes
• Other (department approved): No

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.

• On Call* Yes

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area No

QUALIFICATIONS

EDUCATION

• Bachelor’s degree or higher from an accredited school of Nursing
• Master’s degree preferred

EXPERIENCE

• Seven years of hospital clinical nursing experience, which includes five years in utilization review and/or case management

LICENSES AND CERTIFICATIONS
Required

• RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency) and
• Magnet ANCC-recognized Case Management certification: ACHPN-HPCC or CCM or CMC or ACM-NBCM or CDCES or CHPN-HPCC or CMGT-BC or CM-ABOHN or CMCN or ANCC-NCM