Utilization Review RN

Overview

Baylor St. Luke's Medical Center is an 881-bed quaternary care academic medical center that is a joint venture between Baylor College of Medicine and CHI St. Luke's Health. Located in the Texas Medical Center the hospital is the home of the Texas Heart® Institute a cardiovascular research and education institution founded in 1962 by Denton A. Cooley MD. The hospital was the first facility in Texas and the Southwest designated a Magnet® hospital for Nursing Excellence by the American Nurses Credentialing Center receiving the award five consecutive times. Baylor St. Luke's also has three community emergency centers offering adult and pediatric care for the Greater Houston area.

Responsibilities

1. At the request of third party payers, Provides concurrent and retrospective reviews in an effort to extend authorized

days and ensure reimbursement due for services provided

1. Subject matter expert regarding clinical appropriateness and level of care for CIC staff as well as Patient Access

Services and Patient Financial Services staff. Reviews on referral cases to assist in determination of clinical

appropriateness for level of care and Medicare/Medicaid and Managed Care related issues

1. Reviews all patient documentation in response to letters of denial for reimbursement. Assess individual situations

and makes appropriate referrals to physician advisor. Implements appeal process

1. Serves as resource for case management and social service professionals with regard to managed care contract

interpretation

1. Provides information to CIC staff regarding medical record coding

JOB DESCRIPTION

Page 2 of 89 JOB DESCRIPTION MASTER TEMPLATE

1. Educates staff with updates in Medicare Medicaid and Managed care initiatives

2. Initiates and Coordinates orientation for all new case management professionals to the department

3. Completes quality monitoring of the case management professionals documentation to the department standards

on a weekly basis using a tool designated to measure compliance to standards of practice. Provides feedback to

leadership and individuals in a professional manner

1. Completes data collection, tracks and trends information on denials related to medical necessity. Identifies

performance improvement opportunities and collaborates with all levels of staff to develop and implement process

improvements

1. Completes data collection, analysis and project development for Medicare/Medicaid and managed care initiatives.

Identifies performance improvement opportunities and collaborates with all levels of staff to develop and implement

process improvements

The job summary and responsibilities listed above are designed to indicate the general nature of the work performed

within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities

required of employees assigned to this job. Employees may be required to perform other duties as assigned.

Qualifications

Required:

-Associate's Degree

-Registered Nurse (RN)

-Two (2) years of experience

-Knowledge of case management, working of Medicare, Medicaid and private insurance

-Ability to interact professionally with case management staff, physicians and payers

• If offered the position, you will have 90 days to pass the MCG competency test. However, training and support will be provided beforehand and you will be given four attempts to pass the test with a score of 90. If you are unable to pass the test, your employment will be immediately terminated. There will be additional support provided if you do not pass the first three tests, up to the fourth test.

Preferred:

Bachelors Degree (BSN)

Pay Range

$40.66 - $58.96 /hour

We are an equal opportunity/affirmative action employer.