Top 19 Utilization review nurse Jobs in Shenandoah, Tx

Case Manager (RN) - PRN
Houston Methodist The Woodlands Hospital —The Woodlands, TX
- PRN
- Acute care
- Nursing
- Microsoft Excel
13d
Case Manager (RN) - PRN
Houston Methodist The Woodlands Hospital —The Woodlands, TX
- Weekends as needed
- Acute care
- Nursing
- Microsoft Excel
13d
Nurse - Clinical Review
HealthHelp - A WNS Company —Houston, TX
- $65,000 - $75,000 a year
- Email
- Remote
- Nursing
- Microsoft Excel
- LVN
- Health insurance
- Dental insurance
Quick Apply
Staff Nurse Outpatient Clinic PHP/IOP CCC
Carrus Health —Conroe, TX
- RN License
- Computer literacy
- BLS Certification
Quick Apply
Staff Nurse Outpatient Clinic PHP/IOP CCTB
Carrus Health —Tomball, TX
- RN License
- Computer literacy
- BLS Certification
Quick Apply
Staff Nurse Outpatient Clinic PHP/IOP CCKW
Carrus Health —Kingwood, TX
- RN License
- Computer literacy
- BLS Certification
Quick Apply
Bilingual Nurse Case Manager
Suvida Healthcare —Houston, TX
- Full-time
- Hybrid work
- Spanish
- Nursing
- RN License
Quick Apply
Nurse Care Manager (Contract)
Suvida Healthcare —Houston, TX
- Contract
- Hybrid work
- Spanish
- Nursing
- RN License
Quick Apply
MDS Coordinator- RN
Houston Heights Nursing and Rehabilitation Center —Houston, TX
- Full-time
- Nursing
- Skilled nursing facility
- LVN
Quick Apply
10d
MDS Coordinator - LVN
Houston Heights Nursing and Rehabilitation —Houston, TX
- Full-time
- Nursing
- Skilled nursing facility
- LVN
Quick Apply
10d
Nurse Practitioner - N. Houston
Clay Consulting —Houston, TX
- $120,000 - $150,000 a year
- Extended hours
- Nursing
- Blood sampling
- Microsoft Excel
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Director of Nursing
North Houston Transitional Care —Houston, TX
- Full-time
- Nursing
- RN License
- Bachelor of Science
Quick Apply
Appeals Professional III (Licensed Clinician)
Tanaq Support Services LLC —United States
- Full-time
- Remote
- Nursing
- RN License
- Writing skills
9d

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Case Manager (RN) - PRN
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RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if…
13d
Case Manager (RN) - PRN
Houston Methodist The Woodlands Hospital —The Woodlands, TX
RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if…
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utilization review nurse jobs near shenandoah, tx

Case Manager (RN) - PRN

Houston Methodist The Woodlands Hospital -
The Woodlands, TX

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Job Details

PRN
13 days ago

Qualifications

Customer communication
Microsoft Excel
Inpatient experience
Utilization review
RN License
Writing skills
In-person customer service
English
Medicaid health insurance
Managing patients as a nurse case manager
Medicare regulations
Utilization management
Resource utilization in healthcare
Medicaid
Healthcare reimbursement methods
Hospital experience

Full Job Description

PRN, Weekends

At Houston Methodist, the Case Manager PRN (CM) position is a licensed registered nurse (RN) who comprehensively plans for case management of a target patient population on a designated unit(s). This position works with the physicians and interprofessional health care team to facilitate and maintain compassionate, efficient quality care and achievement of desired treatment outcomes. The CM PRN holds joint accountability with social worker for discharge planning and continuity of care and assures that admission and continued stay are medically necessary and communicates clinical information to payors to ensure reimbursement. The CM PRN helps drive change by identifying areas where performance improvement is needed (e.g., day-to-day workflow, education, process improvements, patient satisfaction).

FLSA STATUS
Non-exempt

QUALIFICATIONS

EDUCATION

Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certificates, Licenses and Registrations section.

EXPERIENCE

Three (3) years hospital clinical nursing experience which includes two (2) years in case management

LICENSES AND CERTIFICATIONS
Required

RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)

SKILLS AND ABILITIES

Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations.
Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security.
Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles.
Strong assessment, organizational and problem-solving skill as evidenced by capacity to prioritize multiple tasks and role components
Knowledge of Medicare, Medicaid and Managed Care requirements
Comprehensive knowledge of community resources, health care financial and payer requirements/issues, and eligibility for state, local and federal programs
Comprehensive knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement.
Understanding of pre-acute and post-acute venues of care and post-acute community resources.
Ability to work independently
Strong assessment, organizational and problem-solving skill as evidenced by capacity to prioritize multiple tasks and role components
Demonstrates critical thinking and makes decisions using evidence-based analytical approach in interactions with physicians, payors, and patients and their families

ESSENTIAL FUNCTIONS

PEOPLE ESSENTIAL FUNCTIONS

Collaborates with the physician and all members of the interprofessional health care team to facilitate care for designated case load; monitors the patient’s progress, intervening as needed to ensure that the plan of care and services provided are patient-focused, high quality, efficient, and cost-effective; facilitates timely: • completion and reporting of diagnostic testing; • completion of treatment plan and discharge plan; • modification of plan of care, as necessary, to meet the ongoing needs of the patient; • assignment of appropriate levels of care; • completion of all required documentation in EPIC and MIDAS
Serves as a preceptor, as appropriate, and implements staff education specific to patient populations and unit processes; coaches and mentors other staff and students. Serves a resource for case management and social work resources and needs for the department and the hospital.

SERVICE ESSENTIAL FUNCTIONS

Performs review for medical necessity of admission, continued stay and resource use, appropriate level of care and program compliance. Identifies when services no longer meet InterQual/Millman l criteria, initiates discussion with attending physicians, coordinates with the external case manager to facilitate discharge planning, seeks assistance from the physician advisor, if needed, and informs management of the possible need for issuing Medicare Hospital Initiated Notice of Non-coverage.
Applies approved utilization criteria to monitor appropriateness of admissions, level of care, resource utilization, and continued stay. Reviews level of care denials to identify trends and collaborate with team to recommend opportunities for process improvement.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

Documents assessment and interventions efficiently and effectively.
Plans for routine/difficult discharge and anticipates/prevents and manages emergent situations. Specific focus given to discharge plan and elimination of barriers.
Performs post-discharge review by analyzing the inpatient record to ensure that compliance with quality indicators are met. Intervenes and takes appropriate action to foster real-time compliance with CMS guidelines and other performance measures associated with certification programs and other regulatory, national, regional or locally- sponsored quality programs. Provides reports, as needed, to appropriate parties showing: • compliance with established governmental and/or institutional rules and regulations • analysis of problematic areas, and • actions taken to improve compliance
Conducts chart audits and performs peer-to-peer evaluations for continuous quality improvement.
Identifies opportunities to improve patient satisfaction with focus on discharge domain and collaborates with unit leadership to implement evidence-based patient engagement strategies.

FINANCE ESSENTIAL FUNCTIONS

Monitors Length of Stay (LOS) for case load on an ongoing basis. Identifies population and/or service-specific trends impacting LOS and addresses/resolves problems impeding treatment progress. Proactively takes action to achieve continuous improvement and expedite care/facilitate discharge. Contributes to meeting departmental financial target on scorecard
Manages all patients in Observation Status, daily, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital.
Secures reimbursement for hospital services by communicating medical information required by all external review entities, managed care contracts, insurers, fiscal intermediaries, and state and federal agencies. Responds to requests for information, monitors covered days, and initiates review to assure that all days are covered and reimbursable.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

Provides education to unit-based physicians, nurses, and other healthcare providers on any case management topics.
Identifies opportunity for practice changes. Offers innovative solutions through evidence-based practice/performance improvement projects and shared governance activities.

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

- Uniform: No
- Scrubs: No
- Business professional: Yes
- Other (department approved): No

ON-CALL*

- Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.
- On Call* Yes

TRAVEL**

**Travel specifications may vary by department**

- May require travel within the Houston Metropolitan area Yes
- May require travel outside Houston Metropolitan area No

QUALIFICATIONS

EDUCATION

Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certificates, Licenses and Registrations section.

EXPERIENCE

Three (3) years hospital clinical nursing experience which includes two (2) years in case management

LICENSES AND CERTIFICATIONS
Required RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)

Company Profile:

Houston Methodist The Woodlands Hospital opened in June 2017. This 725,000-square-foot, full-service, acute-care hospital offers many of the same services as our flagship hospital in the Texas Medical Center. Also, on the beautiful hospital campus, located at the intersection of Interstate 45 and Texas State Highway 242, are two medical office buildings, which include a Breast Care Center; Cancer Center; infusion center; heart and vascular services; neurology; orthopedics and sports medicine; rehabilitation services; wellness services; an outpatient laboratory; and several other multispecialty physician practices. In January 2022, Houston Methodist The Woodlands opened Healing Tower — a $250 million expansion project that added 106 beds, focused on medical-surgical and women’s services, and provided nine operating rooms. The project also included the expansion of the endoscopy center, emergency department and diagnostic imaging department with an enhanced neurodiagnostic and interventional center.

Houston Methodist is an Equal Opportunity Employer.

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utilization review nurse jobs in shenandoah, tx

Case Manager (RN) - PRN

Case Manager (RN) - PRN

Nurse - Clinical Review

Staff Nurse Outpatient Clinic PHP/IOP CCC

Staff Nurse Outpatient Clinic PHP/IOP CCTB

Staff Nurse Outpatient Clinic PHP/IOP CCKW

Bilingual Nurse Case Manager

Nurse Care Manager (Contract)

MDS Coordinator- RN

MDS Coordinator - LVN

Nurse Practitioner - N. Houston

Director of Nursing

Appeals Professional III (Licensed Clinician)

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