EL PASO CHILDRENS HOSPITAL CORPORATION
Location
El Paso, Texas
The Utilization Review Nurse monitors hospital services to ensure the appropriateness of admissions and extended stays. They collaborate with physician advisers to support policy development and manage clinical denials related to medical necessity.
Candidates must hold a current Texas RN license and have at least two years of experience in utilization management. A degree in nursing is required, with a preference for a Bachelor of Science in Nursing (BSN).
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.
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