Utilization Review Case Mgr - Galv. Campus Utilization Mgt (10hr shifts)

Required Education / Experience:

Graduation from an accredited school of professional nursing and current Texas Nursing licensure as a professional registered nurse.  Minimum of three years of full time wage earning experience as a professional nurse in a health care setting.

Job Description :

Performs technical and administrative work required to evaluate the necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities.  Supports the UTMB Utilization Management Program utilizing clinical knowledge, expertise, and criteria guidelines.

Major Duties / Critical Tasks:

• Implements Utilization review procedures by prospectively, concurrently, and retrospectively assessing the clinical information against pre-established criteria, guidelines, and protocols for pre-admissions, scheduled admissions, emergency care, scheduled surgery (Second Surgical Opinion), clinic and other referrals and transfers into hospital.
• Monitors a mechanism for the review of quality of care issues arising during concurrent review, identifies area of potential medical liability and communicates to appropriate leadership
• Monitors and facilitates appropriate utilization of resources.
• Assigns and monitors lengths of stay for all admissions.
• Tracks and reports trends of inappropriate resource utilization to Director/Assistant Director of Utilization Management.
• Maintains a documentation system of all review activities and enters appropriate variances using the approved variance codes.
• Maintains a mechanism for the review of quality of care issues arising during the review process and identifies areas of potential medical liability.
• Collaborates with Case Management, Patient Placement Center to coordinate authorization of scheduled and unscheduled admissions and observation assignments.
• Supports multi-disciplinary strategies to reduce length of stay, reduce resource consumption, and achieve positive patient outcomes.
• Educates the Medical Staff and Nursing Staff on Utilization Management and provides specific information related to case types, including financial data.
• Functions as a resource to physicians and nursing staff regarding approved criteria, practice guidelines, and alternative treatment options.
• Participates in identifying/analyzing aggregate variances and participates with the team in formulating possible solutions to problems identified.
• Maintains clinical expertise in specialty area and/or general nursing.
• Assumes responsibility for remaining current on job-related knowledge and skills and ongoing education/in service/certification requirements.

Salary:

Salary commensurate with experience 

Schedule:

10 hour shifts on Saturday, Sunday, Wednesday, Thursday w/ rotating holidays

Equal Employment Opportunity

UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a Federal Contractor, UTMB Health takes affirmative action to hire and advance protected veterans and individuals with disabilities.