Utilization Review RN

Baylor St. Luke’s Medical Center is an 881-bed quaternary care academic medical center that is a joint venture between Baylor College of Medicine and CHI St. Luke’s Health. Located in the Texas Medical Center, the hospital is the home of the Texas Heart® Institute, a cardiovascular research and education institution founded in 1962 by Denton A. Cooley, MD. The hospital was the first facility in Texas and the Southwest designated a Magnet® hospital for Nursing Excellence by the American Nurses Credentialing Center, receiving the award five consecutive times. Baylor St. Luke’s also has three community emergency centers offering adult and pediatric care for the Greater Houston area. 

CHI St. Luke’s Health, now part of CommonSpirit Health formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health, has been serving our community since 1954. We proudly provide a vast array of services that help us keep our community safe and healthy. Our world needs compassion like never before. Our communities need caring, and our families need protection. With our combined resources, we are committed to building healthy communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen, both inside our hospitals and out in the community. This role will allow you to give back to our community and broaden your healthcare skills. 

We offer the following benefits to support you and your family:

• Health/Dental/Vision Insurance
• Free Premium Membership to Care.com with preloaded credits for children and dependent adults
• Care for Caregivers: Resilience Through Adversity is a series of sessions designed to help caregivers build their resilience and advance their mental well-being during these difficult times
• Flexible spending accounts
• Voluntary Protection: Group Accident, Critical Illness, and Identity Theft
• Employee Assistance Program (EAP) for you and your family
• Paid Time Off (PTO)
• Tuition Assistance for career growth and development
• Matching Retirement Programs
• Wellness Programs

1. At the request of third party payers, Provides concurrent and retrospective reviews in an effort to extend authorized
days and ensure reimbursement due for services provided

2. Subject matter expert regarding clinical appropriateness and level of care for CIC staff as well as Patient Access
Services and Patient Financial Services staff. Reviews on referral cases to assist in determination of clinical
appropriateness for level of care and Medicare/Medicaid and Managed Care related issues

3. Reviews all patient documentation in response to letters of denial for reimbursement. Assess individual situations
and makes appropriate referrals to physician advisor. Implements appeal process

4. Serves as resource for case management and social service professionals with regard to managed care contract
interpretation

5. Provides information to CIC staff regarding medical record coding

JOB DESCRIPTION

Page 2 of 89 JOB DESCRIPTION MASTER TEMPLATE

6. Educates staff with updates in Medicare Medicaid and Managed care initiatives

7. Initiates and Coordinates orientation for all new case management professionals to the department

8. Completes quality monitoring of the case management professionals documentation to the department standards
on a weekly basis using a tool designated to measure compliance to standards of practice. Provides feedback to
leadership and individuals in a professional manner

9. Completes data collection, tracks and trends information on denials related to medical necessity. Identifies
performance improvement opportunities and collaborates with all levels of staff to develop and implement process
improvements

10. Completes data collection, analysis and project development for Medicare/Medicaid and managed care initiatives.
Identifies performance improvement opportunities and collaborates with all levels of staff to develop and implement
process improvements

The job summary and responsibilities listed above are designed to indicate the general nature of the work performed
within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities
required of employees assigned to this job. Employees may be required to perform other duties as assigned.

Required:

-Associate’s Degree

-Registered Nurse (RN)

-Two (2) years of experience

-Knowledge of case management, working of Medicare, Medicaid and private insurance

Preferred:

Bachelors Degree (BSN)