RN - Utilization Management - Full Time
Titus Regional Medical Center
Job: RN - Utilization Management
Classification: Hourly/Non-Exempt
Job Category: 2 Professionals
Position Summary
The Utilization Management RN is responsible for evaluating medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities within the acute hospital setting. This role supports timely and effective patient care while ensuring compliance with payer requirements, Medicare/Medicaid guidelines, and hospital policies. The UM RN works closely with providers, nursing staff, case managers, and insurance representatives to promote appropriate resource utilization and high-quality care.
Essential Functions
-Knows and conforms to the Texas Nursing Practice Act, the Boards' rules and regulations as well as Federal, State, or local laws, rules, or regulations affecting the RN's current area of nursing practice.
-Conducts Clinical Reviews: Perform initial, concurrent, and retrospective reviews to determine medical necessity using evidence-based criteria (e.g., InterQual, MCG).
-Reviews inpatient admissions, observation status, extended stays, and transfers.
-Payer Communication: Submits clinical reviews to third-party payers.
-Responds to insurance queries and participates in denial management and appeals.
-Collaborates with Clinical Teams: Partner with physicians, nursing, case management, and social services to optimize patient care and length of stay.
-Escalates cases to the physician advisor or medical director as needed.
-Documentation & Reporting: Accurately documents UM activities and maintains records per hospital, CMS, and accrediting body standards.
-Compliance & Education: Stays current with regulatory changes affecting UM practices.
-Keeps director abreast of actions with patients, physicians/administrators, etc.
-Able to work within EPIC and Indicia with adeptness and ease.
-Participates in the daily huddle and coordinates care of the patient with the whole team.
-Demonstrates an understanding of the operation of a health care computer system.
-Performs general clerical duties as needed.
-Demonstrates knowledge of utilization and financial issues of an acute health care facility.
-Demonstrates effective oral and written communication skills.
-Demonstrates supervision and leadership skills.
-Adheres to and follows all patient experience initiatives.
-Reports to and departs from work on time and as scheduled.
-Performs other duties as assigned.
-Must be able to deal with stress while maintaining composure.
-Follows and adheres to TRMC vaccine policy(s) mandated by the Centers for Medicare & Medicaid Services (CMS).
Skills and Competencies:
-Knowledge of InterQual, MCG, or similar utilization review criteria.
-Understanding of Medicare/Medicaid, managed care, and commercial payer requirements.
-Strong critical thinking, clinical judgment, and communication skills.
-Proficient with EHR systems and UM software.
-Ability to work independently in a resource-limited environment
Work Experience
-Two years of Critical Care experience preferred.
-Two years of Utilization Management experience preferred.
Education
-Registered Nurse currently licensed to practice in the State of Texas required.
-CCM (Certified Case Manager) or ACM (Accredited Case Manager) preferred.
-BLS (Basic Life Support) within 30 days of hire date required.
Physical Demands and Work Environment
Lifting/Carrying Pushing/Pulling
Lbs. % Time Lbs. % Time
1-10 34-66 1-10 34-66
11-20 0-33 11-20 0-33
21-50 0-33 21-50 0-33
51-75 0-33 51-75 0-33
76-100 None 76-100 None
Movement % Time
Bend/Stoop/Twist 0-33
Crouch/Squat 0-33
Kneel/Crawl 0-33
Reach above Shoulder 0-33
Reach below Shoulder 0-33
Repetitive Arm 0-33
Repetitive Hand 34-66
Grasping 34-66
Squeezing 34-66
Climb Stairs 0-33
Walking Uneven 0-33
Walking Even 34-66
Environment % Time
Indoors 67-100
Outdoors 0-33
Extreme Heat None
Dusty None
Excessive Noise 34-66
Equipment % Time
Motor Vehicles None
Foot Pedals None
Extreme Heat None
Dusty None
Excessive Noise 0-33
Work near % Time
Machinery None
Electricity 0-33
SHARPS 0-33
Chemicals 0-33
Fumes 0-33
Heights None
Vision
Depth Perception Required
< 20" Required
Color Not Required
Peripheral Required
Endurance Hours at Once Total in 12HR
Sit 4 8
Stand 1 2
Walk 1 2
ACKNOWLEDGEMENT:
By electronically acknowledging this job description, I certify that I have been given the opportunity to review this job description. I understand that this job description is intended to indicate the kinds of tasks and levels of difficulty that will be required of positions given this title. It is not intended to limit or in any way modify the right of any supervisor to assign, direct and control the work of employees under supervision. The use of a particular expression or illustration describing duties shall not be held to exclude other duties not mentioned that are similar kind or level of difficulty.
Classification: Hourly/Non-Exempt
Job Category: 2 Professionals
Position Summary
The Utilization Management RN is responsible for evaluating medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities within the acute hospital setting. This role supports timely and effective patient care while ensuring compliance with payer requirements, Medicare/Medicaid guidelines, and hospital policies. The UM RN works closely with providers, nursing staff, case managers, and insurance representatives to promote appropriate resource utilization and high-quality care.
Essential Functions
-Knows and conforms to the Texas Nursing Practice Act, the Boards' rules and regulations as well as Federal, State, or local laws, rules, or regulations affecting the RN's current area of nursing practice.
-Conducts Clinical Reviews: Perform initial, concurrent, and retrospective reviews to determine medical necessity using evidence-based criteria (e.g., InterQual, MCG).
-Reviews inpatient admissions, observation status, extended stays, and transfers.
-Payer Communication: Submits clinical reviews to third-party payers.
-Responds to insurance queries and participates in denial management and appeals.
-Collaborates with Clinical Teams: Partner with physicians, nursing, case management, and social services to optimize patient care and length of stay.
-Escalates cases to the physician advisor or medical director as needed.
-Documentation & Reporting: Accurately documents UM activities and maintains records per hospital, CMS, and accrediting body standards.
-Compliance & Education: Stays current with regulatory changes affecting UM practices.
-Keeps director abreast of actions with patients, physicians/administrators, etc.
-Able to work within EPIC and Indicia with adeptness and ease.
-Participates in the daily huddle and coordinates care of the patient with the whole team.
-Demonstrates an understanding of the operation of a health care computer system.
-Performs general clerical duties as needed.
-Demonstrates knowledge of utilization and financial issues of an acute health care facility.
-Demonstrates effective oral and written communication skills.
-Demonstrates supervision and leadership skills.
-Adheres to and follows all patient experience initiatives.
-Reports to and departs from work on time and as scheduled.
-Performs other duties as assigned.
-Must be able to deal with stress while maintaining composure.
-Follows and adheres to TRMC vaccine policy(s) mandated by the Centers for Medicare & Medicaid Services (CMS).
Skills and Competencies:
-Knowledge of InterQual, MCG, or similar utilization review criteria.
-Understanding of Medicare/Medicaid, managed care, and commercial payer requirements.
-Strong critical thinking, clinical judgment, and communication skills.
-Proficient with EHR systems and UM software.
-Ability to work independently in a resource-limited environment
Work Experience
-Two years of Critical Care experience preferred.
-Two years of Utilization Management experience preferred.
Education
-Registered Nurse currently licensed to practice in the State of Texas required.
-CCM (Certified Case Manager) or ACM (Accredited Case Manager) preferred.
-BLS (Basic Life Support) within 30 days of hire date required.
Physical Demands and Work Environment
Lifting/Carrying Pushing/Pulling
Lbs. % Time Lbs. % Time
1-10 34-66 1-10 34-66
11-20 0-33 11-20 0-33
21-50 0-33 21-50 0-33
51-75 0-33 51-75 0-33
76-100 None 76-100 None
Movement % Time
Bend/Stoop/Twist 0-33
Crouch/Squat 0-33
Kneel/Crawl 0-33
Reach above Shoulder 0-33
Reach below Shoulder 0-33
Repetitive Arm 0-33
Repetitive Hand 34-66
Grasping 34-66
Squeezing 34-66
Climb Stairs 0-33
Walking Uneven 0-33
Walking Even 34-66
Environment % Time
Indoors 67-100
Outdoors 0-33
Extreme Heat None
Dusty None
Excessive Noise 34-66
Equipment % Time
Motor Vehicles None
Foot Pedals None
Extreme Heat None
Dusty None
Excessive Noise 0-33
Work near % Time
Machinery None
Electricity 0-33
SHARPS 0-33
Chemicals 0-33
Fumes 0-33
Heights None
Vision
Depth Perception Required
< 20" Required
Color Not Required
Peripheral Required
Endurance Hours at Once Total in 12HR
Sit 4 8
Stand 1 2
Walk 1 2
ACKNOWLEDGEMENT:
By electronically acknowledging this job description, I certify that I have been given the opportunity to review this job description. I understand that this job description is intended to indicate the kinds of tasks and levels of difficulty that will be required of positions given this title. It is not intended to limit or in any way modify the right of any supervisor to assign, direct and control the work of employees under supervision. The use of a particular expression or illustration describing duties shall not be held to exclude other duties not mentioned that are similar kind or level of difficulty.
JOB SUMMARY
RN - Utilization Management - Full Time
Titus Regional Medical Center
Mt Pleasant
10 days ago
N/A
Full-time
RN - Utilization Management - Full Time