Utilization Review Nurse-(HCPC) in Houston, TX

Position Summary: Assists in the coordination of the appropriate utilization of services and resources of patient care and continuum at HCPC. Location: Dunn Behavioral Sciences Center/HCPC at UTHealth Houston Dept.: BSC Patient Revenue Cycle Status: Full-Time FLSA: Exempt Position Key Accountabilities: 1. Assists in the coordination of all aspects of concurrent review process for individual cases. 2. Coordinates clinical documentation to third-party payers and state agencies to secure timely payment for patient charges. 3. Participates in the utilization review and/or quality assurance programs. 4. Conducts various types of case reviews for quality and appropriate medical management, cost containment, peer review and rehabilitation. 5. Implements utilization review policies and procedures. 6. Reviews to determine appropriateness and medical necessity of admissions, continued stay and use of ancillary services. 7. Monitors third-party administrator and agency files to oversee contractor handling. 8. Performs data entry, which includes application of criteria sets and Diagnosis Review Groups (DRG) for the utilization review process. 9. Maintains a permanent record of all utilization review records, identifies problems, and follows through with resolutions. 10. Prepares reports and analyzes statistical data. 11. Other duties as assigned. Certification/Skills: • Registered Nurse (RN) State Licensure or Nurse Licensure Compact (NLC) by Texas Board of Nursing (BON) required Minimum Education: Bachelor’s degree in Nursing from an accredited school. Minimum Experience: Three years experience in nursing, preferably in Psychiatric nursing. Physical Requirements: Exerts up to 50 pounds of force occasionally and/or up to 20 pounds frequently and/or up to 10 pounds constantly to move objects. Security Sensitive: This position is a security-sensitive position pursuant to Texas Education Code §51.215 and Texas Government Code §411.094. To the extent that a position requires the holder to research, work on, or have access to critical infrastructure as defined in Texas Business and Commerce Code §117.001(2), the ability to maintain the security or integrity of the infrastructure is a minimum qualification to be hired for and to continue to be employed in that position. Personnel in such positions, and similarly situated state contractors, will be routinely reviewed to determine whether things such as criminal history or continuous connections to the government or political apparatus of a foreign adversary might prevent the applicant, employee, or contractor from being able to maintain the security or integrity of the infrastructure. A foreign adversary is a nation listed in 15 C.F.R. §791.4. Residency Requirement: Employees must permanently reside and work in the State of Texas.