RN/Registered Nurse - Utilization Management, Clinical Reviews - PRN

About the position The Registered Nurse (RN) in Utilization Management is responsible for conducting clinical reviews and determining the initial admission status and level of care recommendations for inpatient, observation, and outpatient admissions within the Texas Health Resources (THR) system. This position is 100% remote, but candidates must reside in Texas, preferably in the Dallas-Fort Worth area. The role requires a flexible schedule, as it operates on a PRN basis, covering day shifts from 6:45 AM to 3:15 PM, including both weekdays and weekends. In this role, the RN will conduct initial admission reviews according to established criteria for various types of insurance, including commercial, Medicare Advantage, and self-pay. The RN will also provide clinical information to payors for pre-certification processes and ensure that proper authorization requirements are met for each admission. This includes obtaining necessary pre-certifications and authorizations from third-party payers and ensuring compliance with medical necessity criteria and payer guidelines. The RN will collaborate with medical and nursing staff, health information management, and payers to address potential reimbursement issues and evaluate concurrent potential denials or payment issues. The role requires strong communication skills to facilitate physician peer-to-peer reviews and to discuss working Diagnosis-Related Group (DRG) issues with Care Transition Managers. The RN will be expected to work independently in a fast-paced environment while maintaining high professional standards and demonstrating leadership and teamwork skills. Responsibilities • Determine initial admission status and level of care recommendations for inpatient, observation, and outpatient admissions. , • Conduct initial admission reviews according to established criteria for various insurance types. , • Provide clinical information to payors for pre-certification processes. , • Ensure proper authorization requirements are met for each admission. , • Obtain or facilitate acquisition of urgent/emergent authorizations and continued stay authorizations as needed. , • Provide consultation to medical and nursing staff regarding reimbursement issues. , • Evaluate concurrent potential denials or payment issues and communicate with admitting physicians. , • Collaborate and communicate with payers via phone, fax, or computer system. , • Initiate and facilitate physician communication regarding the Utilization Review (UR) process. , • Determine working DRG with each initial review and discuss issues with Care Transition Manager. Requirements • Associate's Degree in Nursing required; Bachelor's Degree in Nursing preferred. , • 5 years of inpatient clinical nursing experience in an acute hospital setting required. , • 1 year of Utilization Management experience required. , • Experience in case management and/or application of medical necessity criteria preferred. , • 1 year of UM experience in the last three years preferred. , • Current RN license to practice professional nursing in Texas upon hire required. , • Other Case Management certification within 12 months preferred. , • Other MCG certification within 12 months preferred. , • Interpersonal, analytic, and critical thinking skills for problem solving and decision making required. , • Broad knowledge of reimbursement and regulatory requirements required. , • Ability to work with minimal supervision and in a fast-paced environment required. , • Proficient computer skills with experience in MS Office, internet navigation, and clinically/financially-based software required. Nice-to-haves • Experience in case management preferred. , • Other Case Management certification preferred. , • Other MCG certification preferred. Benefits • Flexible schedule , • Remote work environment , • Collaborative team approach , • Opportunities for growth and professional development , • High quality of patient care through nursing education and research , • Supportive team environment Apply Job!