USPI Memorial Hermann Surgical Hospital Kingwoodis seeking a motivated RN Case Manager to join our team. We have 6 OR rooms and 2 Treatment rooms. We perform outpatient surgical procedures in ENT, General, GI, Gynecology, Ophthalmology, Orthopedic, Pain, Plastic, Podiatry, Spine, Urology. We are looking for a candidate to be available Monday-Friday, schedule subject to changed based on surgical schedule and flow of day. Candidate needs to be available for some early mornings and later evenings.

Job Summary:  

• Collaborates in the process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality, cost effective care. 
• The case management process begins when the patient enters the health care system continues through discharge planning, discharge and post-discharge follow-up.
• The case managers perform utilization management and review functions, peer review relating to utilization review, and follows best practices including CMS, JC and State laws governing medical necessity. All utilization review functions are reported by the case manager to the utilization review committee.

Duties: 

• Pro-actively reviews records and patient admission and treatment plans for medical necessity using evidence based criteria such as InterQual or Milliman.
• Pro-actively works with physicians to obtain the documentation needed to support medical necessity.
• Pro-actively monitors admission status for appropriate status orders and communicates needs to the attending physician.
• Receives Recovery Audit Contractor (RAC) requests documenting date and time of receipt.
• Reviews the records requested by RAC for medical necessity and appropriate documentation to support medical necessity.
• Utilizes physician advisors to assist in the review of RAC requested records.
• Communicates needs and timely submits complete records to the RAC requesting agency by certified mail.
• Tracks the RAC audit and appeal process for submission or extension requests or timely submission of appeals from request to final determination.
• Reports all RAC activity to the UR committee and administration.
• Takes responsibility for the OPPE/FPPE process and works closely with the Peer Review and Credentialing Committee.

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Qualifications: 

Education

• Graduate of an accredited school of nursing; BSN preferred

Licensure/Certification

• Current, active Texas RN licensure required
• Case Management certification preferred, but not required
• BLS required

Specific Job Experience

• Minimum two (2) years acute care experience required
• Previous experience in case management required 

USPI complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce.  If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date.  If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.