Utilization Review Nurse Health Plans - Case Management
CHRISTUS Health · Wichita, KS
Job description
Utilization Review Nurse This position has a remote option for those living close and will be able to come into the hospital as needed. The Utilization Review Nurse is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services "CMS" Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and guidelines related to UM. This nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS. Responsibilities: • Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders. • The prior authorization role completes an assessment of a proposed service to determine if the beneficiary has eligible coverage for the service and if it is medically necessary. • Promote quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence-based clinical guidelines. • Identify and present cases of possible quality of care deviations, questionable admissions, and prolonged lengths of stay to the Medical Director for further determination. • Appropriately refer beneficiaries who have complex or chronic conditions, a need for transition of care, disease management support, or other identifiable needs for coordination of the beneficiary's member's health care for behavioral health care management. • Follow CHRISTUS Health Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI). • Protect the confidentiality of data and intellectual property; assures compliance with national health information guidelines. • Analyze clinical information submitted by medical providers to evaluate the medical necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities. • Perform provider outreach to address post-hospital discharge services, redirection to in-network providers for appropriate steerage, durable equipment usage, and utilization of other medical services and/or procedures and other necessary telephonic follow-up. • Utilize the nursing process and critical thinking skills to provide oversight of services and evaluation of service options. • Ability to work in a variety of settings with culturally diverse communities with the ability to be culturally sensitive and appropriate. • Must have excellent communication skills (written and verbal), clinical judgment, initiative, critical thinking, and problem-solving abilities. • Must be able to take after hour calls to meet business requirements as needed. Job Requirements: Education/Skills • Graduate of an accredited school of vocational nursing or equivalent required • Associate's (ADN) or Bachelor's (BSN) in Nursing preferred Experience • 3 – 5 years of nursing experience preferred • Experience in Microsoft software (e.g., Outlook, Teams, Word, and Excel) required • General computer knowledge and capability to use computers required Licenses, Registrations, or Certifications • LVN license in the state of employment or compact required • RN license in state of employment or compact preferred Work Schedule: 5 Days - 8 Hours Work Type: Full Time
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Registered Nurse EP Lab
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Your future role at a glance Location: Wichita, KS Facility: Ascension Via Christi, St Francis Specialty: Electrophysiology Lab Schedule: Day Shift l Full-time | 4 shifts per week from 7:00am - 5:30pm + call requirements Sign-on bonus: Up to $7,500.00 Via Christi associates are eligible for tuition discounts and priority placement in select healthcare programs through our academic partnership with Wichita State University. Life at Ascension: Where purpose meets opportunity Ascension is a leading nonprofit Catholic health system with a culture and associate experience grounded in service, growth, care and connection. We empower our 97,000+ associates to bring their skills and expertise every day to reimagining healthcare, together. Recognized as one of the Best 150+ Places to Work in Healthcare and a Military-Friendly Gold Employer, you'll find an inclusive and supportive environment where your contributions truly matter. Benefits that help you thrive • Comprehensive health coverage: medical, dental, vision, prescription coverage and HSA/FSA options • Financial security & retirement: employer-matched 403(b), planning and hardship resources, disability and life insurance • Time to recharge: pro-rated paid time off (PTO) and holidays • Career growth: Ascension-paid tuition (Vocare), reimbursement, ongoing professional development and online learning • Emotional well-being: Employee Assistance Program, counseling and peer support, spiritual care and stress management resources • Family support: parental leave, adoption assistance and family benefits • Other benefits: optional legal and pet insurance, transportation savings and more How you'll make an impact in this role • Deliver exceptional direct nursing care by following established evidence-based protocols to ensure the highest standards of safety and clinical excellence for every patient. • Champion patient recovery journeys by continuously monitoring conditions, executing physician orders, and adjusting care plans to respond dynamically to patient needs. • Coordinate multidisciplinary care teams, serving as the central advocate to ensure seamless communication and a holistic approach to patient treatment. • Drive proactive discharge planning in collaboration with the healthcare team to guarantee patients and their families experience a safe, well-prepared transition home or to the next level of care. What minimum requirements you'll need Licensure / Certification / Registration: • Advanced Life Support obtained within 6 Months (180 days) of hire date or job transfer date required. American Heart Association or American Red Cross accepted. • BLS Provider obtained within 1 Month (30 days) of hire date or job transfer date required. American Heart Association or American Red Cross accepted. • Registered Nurse credentialed from the Kansas Board of Nursing obtained prior to hire date or job transfer date required. Education: • Diploma from an accredited school/college of nursing OR Required professional licensure at time of hire required. What additional preferences we're seeking • Proven Intensive Care Unit (ICU) clinical experience, demonstrating the ability to thrive in high-acuity, fast-paced environments. • Technical Competency with critical care medical equipment and specialized ICU technologies. Equal employment opportunity employer Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws. For further information, view the EEO Know Your Rights (English) poster or EEO Know Your Rights (Spanish) poster. Fraud prevention notice Prospective applicants should be vigilant against fraudulent job offers and interview requests. Scammers may use sophisticated tactics to impersonate Ascension employees. To ensure your safety, please remember: Ascension will never ask for payment or to provide banking or financial information as part of the job application or hiring process. Our legitimate email communications will always come from an @ascension.org email address; do not trust other domains, and an official offer will only be extended to candidates who have completed a job application through our authorized applicant tracking system. E-Verify statement Employer participates in the Electronic Employment Verification Program. Please click here for more information.