Utilization Management Nurse III - Case Management
Company: Christus Health
Location: San Antonio
Posted on: May 8, 2025
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Job Description:
Description
Summary: The Utilization Management Nurse III is responsible for
determining the clinical appropriateness of care provided to
patients and ensuring proper hospital resource utilization of
services. This Nurse is responsible for performing a variety of
pre-admission, concurrent, and retrospective UM related reviews and
functions. They must competently and accurately utilize approved
screening criteria (InterQual/MCG/Centers for Medicare and Medicaid
Services "CMS" Inpatient List). They effectively and efficiently
manage a diverse workload in a fast-paced, rapidly changing
regulatory environment and are responsible for maintaining current
and accurate knowledge regarding commercial and government payors
and Joint Commission regulations and guidelines related to UM. This
Nurse effectively communicates with internal and external clinical
professionals, efficiently organizes the financial insurance care
of the patients, and relays clinical data to insurance providers
and vendors to obtain approved certification for services. The
Utilization Management Nurse collaborates as necessary with other
members of the health care team to ensure the above according to
the mission of CHRISTUS. CHRISTUS Santa Rosa Hospital - Westover
Hills (CSRH-WH) is a 150-bed hospital serving the fastest growing
area of San Antonio. Specialized care includes orthopedic and
surgical services, ICU, women's services, a newborn nursery,
comprehensive cardiovascular care from diagnostics to open heart
surgery, vascular lab, sleep center, emergency services, the
CHRISTUS Weight Loss Institute, wound care, rehabilitation, and
more. The campus also boasts an Outpatient Imaging Center and three
medical plazas, one of which houses our CHRISTUS Santa Rosa Family
Medicine Residency Program and CHRISTUS Santa Rosa Family Health
Center. Responsibilities: --- Meets expectations of the applicable
OneCHRISTUS Competencies: Leader of Self, Leader of Others, or
Leader of Leaders. --- Applies demonstrated clinical competency and
judgment in order to perform comprehensive assessments of clinical
information and treatment plans and apply medical necessity
criteria in order to determine the appropriate level of care. ---
Resource/Utilization Management appropriateness: Assess assigned
patient population for medical necessity, level of care, and
appropriateness of setting and services. Utilizes MCG/InterQual
Care Guidelines and/or health system-approved tools to track impact
and variance. --- Uses appropriate criteria sets for admission
reviews, continued-to-stay reviews, outlier reviews, and clinical
appropriateness recommendations. --- Coordinate and facilitate
correct identification of patient status. --- Analyze the quality
and comprehensiveness of documentation and collaborate with the
physician and treatment team to obtain documentation needed to
support the level of care. --- Facilitates joint decision-making
with the interdisciplinary team regarding any changes in the
patient status and/or negative outcomes in patient responses. ---
Demonstrates, maintains, and applies current knowledge of
regulatory requirements relative to the work process in order to
ensure compliance, i. e. IMM, Code 44. --- Demonstrate adherence to
the CORE values of CHRISTUS. --- Utilize independent scope of
practice to identify, evaluate, and provide utilization review
services for patients and analyze information supplied by
physicians (or other clinical staff) to make timely review
determinations, based on appropriate criteria and standards. ---
Take appropriate follow-up action when established criteria for
utilization of services are not met. --- Proactively refer cases to
the physician advisor for medical necessity reviews, peer-to-peer
reviews, and denial avoidance. --- Effectively collaborate with the
Interdisciplinary team including the Physician Advisor for
secondary reviews. --- Proactively review patients at the point of
entry, prior to admission, to determine the medical necessity of a
requested hospitalization and the appropriate level of care or
placement for the patient. --- Review surgery schedule to ensure
planned surgeries are ordered in the appropriate status and that
necessary authorization has been obtained as required by the payor
or regulatory guidance (ie., CMS Inpatient Only List, Payor Prior
Authorization matrix, etc.)--- Regularly review patients who are in
the hospital in Observation status to determine if the patient is
appropriate for discharge or if conversion to inpatient status is
appropriate. --- Proactively identify and resolve issues regarding
clinical appropriateness recommendations, coverage, and potential
or actual payor denials. --- Maintain consistent communication and
exchange of information with payors as per payor or regulatory
requirements to coordinate certification of hospital services. ---
Coordinate and facilitate patient care progression throughout the
continuum and communicate and document to support medical necessity
at each level of care. --- Evaluate care administered by the
interdisciplinary health care team and advocate for standards of
practice. --- Analyze assessment data to identify potential
problems and formulate goals/outcomes. --- Follows the CHRISTUS
Guidelines related to the Health Insurance Portability and
Accountability ACT (HIPPA) designed to prevent or detect
unauthorized disclosure of Protected Health Information (PHI). ---
Attend scheduled department staff meetings and/or interdepartmental
meetings as appropriate. --- Possesses and demonstrates technology
literacy and the ability to work in multiple technology systems.
--- Act as a catalyst for change in the organization; respond to
change with flexibility and adaptability; demonstrate the ability
to work together for change. --- Translate strategies into action
steps; monitor progress and achieve results. --- Demonstrate the
confidence, drive, and ability to face and overcome challenges and
obstacles to achieve organizational goals. --- Demonstrate
competence to perform assigned responsibilities in a manner that
meets the population-specific and developmental needs of patients
served by the department. --- Possess negotiating skills that
support the ability to interact with physicians, nursing staff,
administrative staff, discharge planners, and payers. --- Excellent
verbal and written communication skills, knowledge of clinical
protocol, normative data, and health benefit plans, particularly
coverage and limitation clauses. --- Must adjust to frequently
changing workloads and frequent interruptions. --- May be asked to
work overtime or take calls. --- May be asked to travel to other
facilities to assist as needed. --- Actively participates in
Multidisciplinary/Patient Care Progression Rounds. --- Escalates
cases as appropriate and per policy to Physician Advisors and/or CM
Director. --- Documents in the medical record per regulatory and
department guidelines. --- May be asked to assist with special
projects. --- May serve as a preceptor or orienter to new
associates. --- Assumes responsibility for professional growth and
development. --- Must have familiarity with criteria sets including
InterQual and MCG preferred. --- Must have excellent verbal and
written communication. --- Must have critical and analytical
thinking skills. --- Must have demonstrated clinical competency.
--- Other duties as assigned. Requirements: A. Education/Skills
Keywords: Christus Health, San Marcos , Utilization Management Nurse III - Case Management, Executive , San Antonio, Texas
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