• Implements Utilization review procedures by prospectively, concurrently, and retrospectively assessing the clinical information against pre-established criteria, guidelines, and protocols for pre-admissions, scheduled admissions, emergency care, scheduled surgery (Second Surgical Opinion), and clinic referrals.
• Monitors a mechanism for the review of quality of care issues arising during concurrent review and identifies area of potential medical liability.
• Monitors and facilitates appropriate utilization of resources.
• Assigns and monitors lengths of stay for all admissions.
• Tracks and reports trends of inappropriate resource utilization to Director/Assistant Director of Utilization Management.
• Maintains a documentation system of all review activities and enters appropriate variances using the approved variance codes.
• Maintains a mechanism for the review of quality of care issues arising during the review process and identifies areas of potential medical liability.
• Collaborates with Case Management, Admitting Bed Information Center to coordinate authorization of scheduled and unscheduled admissions and observation assignments.
• Supports multi-disciplinary strategies to reduce length of stay, reduce resource consumption, and achieve positive patient outcomes.
• Educates the Medical Staff and Nursing Staff on Utilization Management and provides specific information related to case types, including financial data.
• Functions as a resource to physicians and nursing staff regarding approved criteria, practice guidelines, and alternative treatment options.
• Participates in identifying/analyzing aggregate variances and participates with the team in formulating possible solutions to problems identified.
• Maintains clinical expertise in specialty area and/or general nursing.
• Assumes responsibility for remaining current on job-related knowledge and skills and ongoing education/in service/certification requirements.
• Utilizes effective communication, conflict management, and negotiation skills.
• Participates in research activities/projects.
• Participates in Committee and Subcommittees associated with Utilization Management.
• Provides assistance regarding clinical issues to non-nursing utilization review staff.
• Contributes to the success of UTMB Managed Care Organization.
• Performs a variety of marginal duties not listed, to be determined and assigned as needed.

Graduation from an accredited school of professional nursing and current Texas Nursing licensure as a professional registered nurse. Minimum of three years of full time wage earning experience as a professional nurse in a health care setting.

Knowledge / Skills / Abilities:

• Must be self-motivated, willing and able to learn multiple aspects of the job.
• Able to demonstrate both written and verbal communication skills.
• Demonstrate excellent interpersonal skills and telephone etiquette.
• Demonstrate history of accuracy, tenacity and attention to detail. 
• Proficient in the use of ICD Coding and CPT coding. Familiarity with DSM coding is helpful.