Children's Health (Dallas) is seeking a Registered Nurse (RN) Med Surg for a nursing job in Dallas, Texas.

• Specialty: Med Surg
• Discipline: RN
• Duration: Ongoing
• Employment Type: Staff

Job Title & Specialty Area: Prospective Review RN
Department: Utilization Management
Location: Dallas
Shift: Day
Job Type: Remote (This position does require on site attendance as needed)

Why Children’s Health?
At Children's Health, our mission is to Make Life Better for Children, and we recognize that their health plays a crucial role in achieving this goal.

Through our cutting-edge treatments and affiliation with UT Southwestern, we strive to deliver an extraordinary patient and family experience, ensuring that every moment, big or small, contributes to their overall well-being.

Our dedication to promoting children's health extends beyond our organization and encompasses the broader community. Together, we can make a significant difference in the lives of children and contribute to a brighter and healthier future for all.

Summary:
The Prospective Review Nurse is responsible for conducting utilization review of scheduled inpatient services requested by Physician/Provider in the prior authorization process. This role will support Ambulatory clinics and Patient Access Service areas; assisting in reviewing medical records for appropriate reimbursement of medically necessary services meeting contractual payor requirements and utilizing nationally recognized criteria guidelines. This includes communication with clinic administrative staff and Physicians/ Providers admitting patients to a Children's Health System of Texas (CHST) facility, and collaboration with the Physician Advisor during the review process. The Prospective Review Nurse will work collaboratively with Utilization Management Nurses to monitor and resolve quality opportunities for appropriate authorization; and Denials Management Specialist to analyze denial data, propose and execute improvements to increase compliance of appropriate authorization process.

Responsibilities:
* In collaboration with Patient Access Services, Ambulatory clinics and UM leadership planning and execution of communication to various facilities, developing workflow processes for referring future inpatient encounters and setting timeframes for processing, initial/ongoing meetings for education of nurse supporting role and established processes, works collaboratively with UM Denials Specialist to identify denial trends and provides feedback to affected areas, collaboratively develops action plans to mitigate denial issues, assist/serve as content expert and resource.
* Functions as point of contact of the hospital's prospective review, providing assistance to all departments to prevent medical necessity and status conflict denials.
* Before completion of payer prior authorization, ensures prior authorization/ prospective review requests are conducted utilizing MCG or Indicia, CHST clinical pathways, and clinical knowledge to determine appropriateness of admission, and level of care. Collaborate with appropriate medical and professional staff on an alternative level of care when appropriate. Assists CHST non-medical staff with issues that require clinical interpretation or explanation; serves as the liaison between Physician/ Providers, or payers for medical knowledge base.
* Utilizes EPIC for chart review to obtain pertinent clinical information supporting appropriate level of care in the prior authorization process. Interacts with medical and professional staff to obtain clinical documentation in EPIC which accurately supports medical necessity.
* Proactively intervenes with medical necessity, or level of care denials by exercising all real-time options to overturn decision. Actions include, but not limited to the use of third party Physician Advisor, facilitation of peer to peer with CHST Physician, or an appeal, prior to scheduled patient admission.
* Participates in Quality Improvement projects as directed; performs audits of medical records as directed; and assists the Utilization Review Team Lead, Prior Authorization and department Directors in preparation for audits and other regulatory activities.
* Identifies and produces creative solutions to problems identified via the prior authorization process.
* Educates clinical and non clinical staff on clinical criteria/guidelines for medical necessity, and setting/level of care based on complex or high cost admissions.
* Accountable for current knowledge of utilization management responsibilities, including: payer information; business rules; regulatory guidelines; and policies and procedures.
* Maintains productivity and optimum case load, delegating appropriately to maximize skills set, productivity and effectiveness.
* Escalate payer problems and trends to Denials Specialist, Team Lead or Director.
* Identifies issues and strategies to modify and/or enhance the utilization management department.
* Advances clinical expertise through attendance at in-hours education opportunities, reading journals, and attendance at
* conferences.
* Attends department/program meetings regularly.
* Maintains a level of productivity and quality consistent with: complexity of the assignment; facility policies and guidelines; established principles, ethics and standards of practice of professional nursing;
* Other job duties as assigned

Credentials:
Essential:
* Registered Nurse

Other information:
WORK EXPERIENCE
* At least 5 years clinical nursing experience (pediatrics preferred) required
* At least 1 year Utilization Review or Case Management experience required
* Appeals experience Pref
* Experience with Interqual or Milliman Pref

EDUCATION
* Four-year Bachelor's degree or equivalent experience Pref

LICENSES AND CERTIFICATIONS
* Registered Nurse Req
* Accredited Case Manager (ACM) or Certified Case Manager (CCM) certification Pref

JOB PROFILE
* Requires in-depth professional knowledge and practical/applied expertise in own discipline and basic knowledge of related disciplines within the broader professional field
* Has knowledge of best practices and how own area integrates with others; demonstrates awareness of the industry, including regulatory, evolving customer demands, and the factors that differentiate the organization in the market
* Acts as a resource for colleagues with less experience; may lead projects with manageable risks and resource requirements
* Solves complex problems and takes a new perspective on existing solutions; exercises judgment based on the analysis of multiple sources of information
* Impacts a range of customer, operational, project or service activities within own team and other related teams; works within broad guidelines and policies
* Works independently, receives minimal guidance
* Explains difficult or sensitive information; works to build consensus

NON-MANAGEMENT SKILLS
* Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
* Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
* Meet patient and patient family needs; take responsibility for a patient's safety, satisfaction, and clinical outcomes; use appropriate interpersonal techniques to resolve difficult patient situations and regain patient confidence.
* Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
* Develop and use collaborative relationships to facilitate the accomplishment of work goals.
* Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
* Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
* Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
* Effectively manage one's time and resources to ensure that work is completed efficiently.
* Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
* Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self impose standards of excellence rather than having standards imposed.
* Assimilate and apply new job-related information in a timely manner.
* Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.

A Place Where You Belong

We put our people first. We welcome, value, and respect the beliefs, identities and experiences of our patients and colleagues. We are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children’s Health a place where everyone can contribute.

 Holistic Benefits – How We’ll Care for You:

· Employee portion of medical plan premiums are covered after 3 years.

· 4%-10% employee savings plan match based on tenure

· Paid Parental Leave (up to 12 weeks)

· Caregiver Leave

· Adoption and surrogacy reimbursement > 

Children's Health (Dallas) Job ID #2​3​9​2​1. Posted job title: Prospective Review RN

At Children's Health, our mission is to Make Life Better for Children for 110 years, and generation to come. We recognize that their health plays a crucial role in achieving this goal. Through our cutting-edge treatments and affiliation with UT Southwestern, we strive to deliver an extraordinary patient and family experience, ensuring that every moment, big or small, contributes to their overall well-being.

Our dedication to promoting children's health extends beyond our organization and encompasses the broader community.

Together, we can make a significant difference in the lives of children and contribute to a brighter and healthier future for all.

• Wellness and fitness programs
• Medical benefits
• Dental benefits
• Vision benefits
• Holiday Pay
• Pet insurance
• Employee assistance programs
• License and certification reimbursement
• Life insurance