Utilization Review RN - Hybrid

About Us Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well. Our Core Values are: • We serve faithfully by doing what's right with a joyful heart. • We never settle by constantly striving for better. • We are in it together by supporting one another and those we serve. • We make an impact by taking initiative and delivering exceptional experience. Benefits Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include: • Eligibility on day 1 for all benefits • Dollar-for-dollar 401(k) match, up to 5% • Debt-free tuition assistance, offering access to many no-cost and low-cost degrees, certificates and more • Immediate access to time off benefits At Baylor Scott & White Health, your well-being is our top priority. Note: Benefits may vary based on position type and/or level Job Summary • You will review patient cases for medical necessity and establish service suitability. You'll educate the healthcare team on resource use to ensure timely care plan follow-through. • Your job includes staying in contact with the patient's health plan and the provider's care coordination departments. Your expertise is needed to review medical necessity. • Working with the team, you'll verify medical records reflect services provided, ensuring quality care and efficient resource use. Schedule • You will work primarily remote. • Will be required to work onsite at a BSW facility for quarterly meetings • Will be required to work onsite at a BSW facility if experience any technical/connection issues Essential Functions of the Role • You will review medical services. Use guidelines to assess appropriateness. • Evaluate patient needs and requirements. • Your duties will include reviewing medical records to confirm that the content supports an appropriate level of care. • Should you encounter cases not meeting medical appropriateness criteria, you'll alert relevant teams and coordinate actions during denials. • As part of your role, you'll also streamline the authorization process and anticipate discharge requirements. • Clear communication of issues or trends impacting specific entities to the appropriate management is expected. • Part of your work will involve identifying and conveying potential quality assurance or risk management issues. • To improve patient care, join projects to enhance care coordination and implement evidence-based procedures for best standards. • In order to enhance the relationship with providers and members, you'll also perform service recovery tasks. Key Success Factors • An advanced understanding of healthcare procedures, treatments, terms, conditions, and equipment. • An ability to see the world from our customers' eyes and find resolutions to fit their needs. • Proficiency in discharge planning, setting case management referral standards, reviewing utilization, and categorizing levels of care. • Excellent communication skills with a knack for expressing your thoughts clearly, whether orally or in writing. • Effective interpersonal abilities to interact positively and cooperatively with a variety of people. • Exceptional critical thinking and problem-solving skills for dealing with complex situations. • The ability to juggle multiple tasks and responsibilities while sticking to deadlines. • Proficiency in scrutinizing, understanding, and applying detailed clinical care documentation. • Computer literacy, especially in Microsoft Office and medical documentation systems. • Case management certifications, such as Certified Case Manager, are beneficial but not necessary for this position. Belonging Statement • We believe that all people should feel welcomed, valued and supported, and that our workforce should be reflective of the communities we serve. Qualifications • Completion of an Associate's Degree in Nursing is necessary. • At least (3) three years of professional experience is required. • You must hold a valid Registered Nurse License (RN).