Utilization Review Specialist

Memorial Hermann - Houston, TX (30+ days ago)4.0

Utilization Review SpecialistMemorial City Hospital
Job Description
Responsible for the clinical appropriateness (utilization) review of inpatients and observation patients in assigned area of admission and patient placement. Utilization reviews may extend through continued stay and involve discharge planning activities under the direction of the RN Case Manager. Typically reports to the Director, Utilization/Case Management.

Graduate of an accredited school of professional nursing. Bachelor’s degree in Nursing preferred.

Two (2) years of post-acute or acute hospital clinical experience required. Three (3) years of experience in quality assurance, utilization review, discharge planning or case management preferred.

Current, unrestricted license/permit to practice as a Registered Nurse (RN) in the State of Texas required. Effective oral and written communication skills.
Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health” through innovation, accountability, empowerment, collaboration, compassion and results while ensuring One Memorial Hermann.


Uses appropriate criteria sets for admission reviews, continuing stay reviews, outlier reviews and clinical appropriateness recommendation.
Takes appropriate follow-up action when established criteria for utilization of services are not met.
Works on appropriate, timely and compliant documentation of clinical criteria set application, coverage determinations and medical necessity.
Coordinates/facilitates patient care progression throughout the continuum and communication and documentation to support medical necessity at each level of care.
Works collaboratively and maintains active communication with physicians, nursing, other members of the multi-disciplinary care team, and payors to effect timely, appropriate patient management.
Proactively identifies/resolves issues regarding clinical appropriateness recommendations, coverage, and potential or actual payor denials.
Able to perform clinical assessment, consistent with scope of licensure.
Serves as a point of escalation for the UR Analyst.
Seeks consultation from appropriate disciplines/departments as required to expedite care, obtain medical necessity documentation, and facilitate discharge.
Utilizes conflict resolution skills as necessary to ensure timely resolution of issues.
Collaborates with the physician and all members of the multidisciplinary team to facilitate utilization management activities for designated area; monitors the patient’s progress, intervening as necessary and appropriate to ensure that the documented plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis:
Completion, documenting and reporting diagnostic testing, treatment plan and discharge plan;
Documenting modifications of plan of care, as necessary, to meet the ongoing needs of the patient;
Preparation of communications to third party payors and other relevant information to the care team (reviews and/or escalations);
Assignment of appropriate levels of care with supporting documentation;
Entry of working DRG in the electronic information systems;
Completion of all required documentation, communication, and escalations (ie: to the medical director or leadership) in the electronic utilization management software program and patient medical records.
Secures appropriate referrals to social service, Home Health Services, SNF and other alternate care services in collaboration with the RN Case Manager.
Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting. Completes Utilization Management and Quality Screening for assigned patients.
Applies approved clinical appropriateness criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Department standards.
Identifies at-risk populations using approved screening tool and follows established reporting procedures.
Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.
Refers cases and issues to Care Management Medical Director in compliance with Department procedures and follows up as indicated.
Communicates with System Care Management Resource Center to facilitate covered day reimbursement and certification for assigned patients. Discusses payor criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed.
Uses quality screens to identify potential issues and forwards information to Clinical Quality Review Department.
Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
Actively participates in clinical performance improvement activities as needed.
Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
Other duties as assigned.