Under the supervision of Director of Utilization or designee – the Utilization Management RN is responsible for assessing the medical appropriateness for Central Health covered healthcare services and monitoring patient progress for concurrent reviews. The Utilization Management RN will work in conjunction with Case Managers, Social Workers, Physicians, care team members and Network Services to improve the patient experience and positive clinical outcomes. The Utilization Management RN will use their clinical knowledge and expertise to make recommendations about the most appropriate course of treatment and may also be involved in the appeals process when necessary. In this role, the Utilization Management nurse play a crucial role in improving the efficiency and effectiveness of the healthcare system. This position models a commitment to the organization's vision/mission/values to support unique patient needs.

This position is an ON-SITE role in Austin, Texas. To be considered for this role, the candidate must reside in the greater Austin/Travis County area.

Essential Functions:

• Perform thorough reviews and manage authorizations for a range of clinical programs within the organization and the network, including but not limited to skilled nursing services, home health services, transitional dialysis program enrollment, durable medical equipment (DME) requests, and a large variety of specialty care services.
• Collaborate with physicians, care teams, and other healthcare providers to assess patient needs, ensure effective communication and coordination, and participate in multidisciplinary meetings as needed to develop tailored care plans.
• Collaborate with appropriate internal stakeholders, develop, implement, and maintain the prior authorization process for Central Health. Document the process appropriately and ensure process is implemented correctly, making adjustments if needed.
• Maintain accurate records of reviews and authorizations, ensuring compliance with standards. Use EHR and other systems to document patient information and authorization statuses. Ensure documentation is current and supports authorization decisions for transparency and accountability.
• Request additional clinical information from relevant healthcare providers to ensure comprehensive data is available for making informed authorization decisions.
• Review and analyze the additional clinical information to assess its impact on the authorization process. Use the gathered information to make well-informed, evidence-based authorization decisions that align with healthcare standards/regulations and Central Health contracts and agreements.
• Effectively communicate with healthcare providers to clarify any ambiguities or obtain further details as needed.
• Document findings and recommendations to support continuity of care and informed decision-making. Documentation may be done in the patient’s medical record or other systems as appropriate.
• Prepare and provide necessary timely and accurate reports and forms, as may be required by Central Health or facility in the performance of utilization review cases.
• Complies with the established timeliness standards for referral and prior authorization procedures.
• Perform medical and administrative services under general guidance and minimal supervision with accountability for specific organizational-level goals.
• Develop and maintain collaborative working relationships that promote a positive image for Central Health with enterprise affiliates, contracted providers, the local provider community, , regulatory agencies, governing bodies, patients, and the community, as appropriate.
• Collaboratively communicate and exchange information, opinions, and feedback in an open, clear, and respectful manner.
• Prioritize duties and responsibilities, demonstrating strong organization and time management skills.

Knowledge, Skills and Abilities:

• Clinical expertise - strong clinical skills are critical to understanding the medical aspects of relevant information.
• Ability to analyze data and reports on significant utilization trends and identify areas for improvement.
• Ability to thrive in a complex and dynamic environment with multidisciplinary, cross-functional teams and matrixed team structures.
• Capability to handle various tasks simultaneously and adapt flexibly within a dynamic work environment.
• Proficiency in understanding the utilization review process, healthcare policies, and compliance regulations.
• Effectively manage stress and sensitive situations, communicate professionally, work well with diverse populations, and be sensitive to economic and cultural considerations.
• Ability to effectively communicate and collaborate with health care professionals, ensure adherence to policies, and conduct thorough utilization reviews.
• Knowledge of best practice and industry standards related to determining the medical necessity of healthcare services.
• Compliance with data confidentiality and security procedures.
• High level skill at building relationships within the organization and with external partners.
• Experience with electronic medical records and healthcare derived data and a working knowledge of the laws and regulations that govern the same.
• High Demonstrated ability to perform complex operations in Microsoft Office Suite.
• High Strong assessment skills, follows standard precautions and maintains confidentiality.
• Exhibit compassion, vulnerability, and empathy when working with patients and advancing Central Health's health equity and DEIB goals.

Minimum Qualifications:

Education:

Graduation from an accredited School of Nursing (Associates Degree, higher degree accepted)

Work Experience:

A minimum of two to three years of nursing experience in an inpatient setting or case management- Required

Licenses and Certifications:

Registered Nurse License in the State of Texas