Utilization Review Nurse
Dallas, TX, United States2w ago
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Key details
- Salary
- $82K–$88K/yr
- Location
- Dallas, TX, United States
- Work style
- Onsite
- Job type
- Full-time
- Function
- Healthcare
- Focus area
- other
- Posted
- 2w ago
Skills
About the role
Please make sure to complete all the questions in the application and continue through to the end in order to sign and submit it.
The preferred work hours are 8:30 am / 9 am - 5 pm / 5:30 pm central time zone.
Responsible for performing Workers’ Compensation utilization review, which includes prospective, concurrent, expedited, and retrospective reviews to determine medical necessity and appropriateness for requested medical care using evidence-based criteria. Through the discharge planning process, identify patients with ongoing case management needs and refer these claimants to the Case Management team for outreach and follow-up.
Essential Duties and Responsibilities:
- Conducts first-level prospective, concurrent, expedited, and retrospective utilization management, including inpatient services, outpatient services, surgeries, and ancillary service requests
- Reviews of all requests for treatment in accordance with specific state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria
- Evaluate treatment requests and review clinical information received with treatment protocols and guidelines, identify medical necessity, and refer to Peer Physician when appropriate. Reviews must be conducted within state jurisdiction and URAC timeframes.
- Review length of stay for inpatient cases when applicable
- Arrange alternative care services/discharge planning and refer to TCM as appropriate for coordinating of services
- Identify & review with Medical Director any case with potential safety issues
- Promote cost-effective health care with an aligned health provider network
- Identify and refer to Telephonic Case Management / Pharmacy TCM
- Coordinate with TCM / Pharmacy TCM to achieve appropriate next steps which align with TCM goals
- Manage determinations within the pharmacy portal
- Perform NY PAR in the onboard system in accordance with NY MTG Guidelines
Additional Functions and Responsibilities
- Demonstrates ability to meet administrative requirements, including productivity, time management, and Quality Assurance standards
- Maintain established template documentation standards adhering to URAC standards and company policies and procedures
- Maintain minimum billing and report billing hours in accordance with case activity and billing practices
- Maintain confidentiality - knowledge of laws and regulations pertaining to HIPPA and PHI
- Other job duties as assigned
Qualifications
Education:
- Diploma, Associate, bachelor’s degree in nursing, or Master’s level (or higher) degree in a Nursing, Health or Human Services field, or equivalent related experience preferred
- A current, unrestricted Registered Nurse (RN) license recognized in the relevant jurisdiction(s) is required. Interstate nurse compact licensure is preferred. The candidate may be required to obtain additional licensure based on jurisdictional assignment.
- CCM, CMCN, CPHUR, CPDM, COHN or CDMS certification preferred
Here are some of the benefits you can enjoy in this role:
- Medical, Dental, Vision Insurance.
- Life and Disability Insurance.
- 401(k) Plan
- Paid Holidays
- Paid Time Off.
- Referral bonus.
Mental and Physical Requirements: [see separate attachment for a copy of checklist of mental and physical requirements]
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MENTAL AND PHYSICAL REQUIREMENTS |
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1. MENTAL EFFORT
a. Reasoning development:
Follow one- or two-step instructions; routine, repetitive task.
Carry out detailed but uninvolved written or verbal instructions; deal with a few concrete variables.
Follow written, verbal, or diagrammatic instructions; several concrete variables.
X Solve practical problems; variety of variables with limited standardization; interpret instructions.
Logical or scientific thinking to solve problems; several abstract and concrete variables.
Wide range of intellectual and practical problems; comprehend most obscure concepts. |
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b. Mathematical development:
Simple addition and subtraction; copying figures, counting, and recording.
Add, subtract, multiply, and divide whole numbers.
X Arithmetic calculations involving fractions, decimals, and percentages.
Arithmetic, algebraic, and geometric calculations.
Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.
Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application. |
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c. Language development:
Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.
Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.
X Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.
Ability to compose original correspondence, follow technical manuals, and have increased contact with people.
Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data. |
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2. PHYSICAL EFFORT
a. Physical activity required to perform the job:
Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
X Light work: a. Exerting up to 20 pounds of force occasionally b. Exerting up to 10 pounds frequently c. Exerting a negligible amount of force constantly to move objects
(If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).
Medium work: a. Exerting up to 50 pounds of force occasionally b. Exerting up to 20 pounds of force frequently c. Exerting up to 10 pounds of force constantly to move objects
Heavy work: a. Exerting up to 100 pounds of force occasionally b. Exerting up to 50 pounds of force frequently c. Exerting up to 20 pounds of force constantly to move objects
Very heavy work: a. Exerting in excess of 100 pounds of force occasionally b. Exerting in excess of 50 pounds of force constantly to move objects c. Exerting in excess of 20 pounds of force constantly to move objects
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Far vision: clarity of vision at 20 feet or more
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