Utilization Review Nurse, FT Days
EL PASO Childrens Hospital Corporation
El Paso, Texas
To monitor adherence to the hospital’s utilization review plan to ensure the effective and efficient use of hospital services. EL PASO Childrens Hospital Corporation is a specialty hospital.
- Shift and hours
- Days Utilization Review Nurse, FT Days
- Unit and setting
- Hospital
- License
- RN license Current RN License to practice in the State of Texas.RN license to practice in Texas
- Term
- Permanent Utilization Review Nurse, FT DaysFull time
Do you qualify?
- License
- RN license to practice in Texas Current RN License to practice in the State of Texas. Check your license
- Education
- Associate's Degree in Nursing Associate’s Degree in Nursing, BSN preferred.
- Experience
- 2 years prior experience with Utilization Management Two (2) years prior experience with Utilization Management.
- Experience
- Experience with InterQual and/or Milliman Care Guidelines Experience with InterQual and/or Milliman Care Guidelines.
- Also asks
- Training and demonstrated competence in negotiations, quality assurance, case management outcomes, and keyboarding/computer use Previous training and demonstrated competence in negotiations, quality assurance, case management outcomes, and keyboarding/computer use.
- Also asks
- Knowledge of managed care, reimbursement and utilization management Knowledge of managed care, reimbursement and utilization management.
- Also asks
- Knowledge of current ICD-10, DRGs, and medical necessity criteria Knowledge of current International Classification of Disease (ICD-10), Diagnostic Related Groups (DRGs), and medical necessity criteria.
- Also asks
- Knowledge of claims denials and appeals processing
- Also asks
- Knowledge of HIPAA standards Knowledge of HIPAA standards.
- Also asks
- Knowledge of various insurance plan coverages for Home Health, DME, SNF, LTAC agencies Knowledge of various insurance plan coverages for Home Health, DME, SNF, LTAC agencies.
- Also asks
- Knowledgeable regarding community resources Knowledgeable regarding community resources.
- Also asks
- Basic computer, word-processing, and spreadsheet skills (Microsoft) Knowledge of basic computer, word-processing, and spreadsheet skills, Microsoft.
- Also asks
- Ability to operate standard office equipment Ability to operate standard office equipment.
- Also asks
- Knowledge of English grammar, punctuation and spelling Knowledge of English grammar, punctuation and spelling.
Preferred
- Education
- BSN
The role and schedule
- Day to day
- Monitor adherence to the utilization review plan To monitor adherence to the hospital’s utilization review plan to ensure the effective and efficient use of hospital services.
- Day to day
- Ensure appropriateness of admissions and extended stays Responsible for ensuring the appropriateness of hospital admissions and extended hospital stays.
- Day to day
- Review, evaluate, and arrange peer-to-peer reviews for clinical denials
- Day to day
- Collaborate with physician advisers to support policy development and process improvement UM nurse will work closely in collaboration with physician advisers to support policy development, and process improvement.
The workplace
El Paso Children's Hospital Corporation is a pediatric specialty hospital located in El Paso, Texas (79905), dedicated to providing compassionate, coordinated, family-centered care for children across the greater El Paso area and the surrounding Southwest Border Region. The hospital operates…
Worth asking
- Can you walk me through base pay range and differentials?
- What should I expect for weekly hours, weekend, holiday, call, and rotation?
More questions to askFewer questions
- What orientation, preceptor time, and ongoing unit support are included?
- How are patient load, floating, and staffing support handled day to day?
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Your fit
On your path
Case Management is a specialty you move into. Bedside years first. That experience is what gets you in.
Original listing
Read full text
To monitor adherence to the hospital’s utilization review plan to ensure the effective and efficient use of hospital services. Responsible for ensuring the appropriateness of hospital admissions and extended hospital stays. An understanding of the severity of an array of illnesses, intensity of service, and care coordination needs are the key, as the nurse must integrate clinical knowledge with billing knowledge to review, evaluate and arrange peer to peers when clinical denials related to medical necessity of the patient while hospitalized. UM nurse will work closely in collaboration with physician advisers to support policy development, and process improvement.
Work
Experience
- Two (2) years prior experience with Utilization Management.
- Previous training and demonstrated competence in negotiations, quality assurance, case management outcomes, and keyboarding/computer use.
- Experience with InterQual and/or Milliman Care Guidelines. Strong organizational and time management skills.
- Ability to work on extremely complex problems where analysis of situation or data requires an evaluation of intangible variance factors.
License/Registration/
Certification
- Current RN License to practice in the State of Texas.
Education and Training
- Associate’s Degree in Nursing, BSN preferred.
Skills
- Ability to utilize proficient verbal, written and interpersonal communication skills.
- Ability to work on extremely complete problems where analysis of situations or data requires an evaluation of intangible variance factors.
- Knowledge of managed care, reimbursement and utilization management.
- Knowledge of current International Classification of Disease (ICD-10), Diagnostic Related Groups (DRGs), and medical necessity criteria.
- Knowledge of claims denials and appeals processing
- Ability to coordinate and manage multiple priorities, projects simultaneously, reprioritizing as necessary
- Ability to self-motivate, multi-task and prioritize in a fast paced environment.
- Ability to use analytical and problem solving skills.
- Knowledge of HIPAA standards.
- Knowledge of various insurance plan coverages for Home Health, DME, SNF, LTAC agencies.
- Works well with people of all social, economic, and cultural backgrounds.
- Strong customer service orientation.
- Knowledgeable regarding community resources.
- Knowledge of basic computer, word-processing, and spreadsheet skills, Microsoft.
- Ability to operate standard office equipment.
- Knowledge of English grammar, punctuation and spelling.
What's around it?
El Paso, TXFrom Census ACS 2024.
Living costs about 10% below the US average
- Median rent
- $1,073/mo
- Household income
- $59,745/yr, all local households, not nurse pay