Cardiac Cath Lab Nurse Reviewer - Quality | M-F

Phelps Health is a 2000-employee-strong hospital and healthcare system serving the heart of small-town Missouri.

No matter where you start with us, we’re committed to taking our team to the top. If you’re ready for the challenge of providing life-saving care or supporting those who do, read on to find your fit in the Phelps Health family.

General Summary

The Cardiac Cath Lab Nurse Reviewer (CCLNR) collects and submits reliable data to the NCDR program by performing high-quality clinical screening, data compilation, documentation and entry into the database of all eligible procedures, in both inpatient and outpatient settings, for Phelps Health. The CCLNR works closely with the members of the Department of Clinical Quality and Measurement to identify opportunities for clinical quality improvement and other special projects as may be identified.

Essential Duties and Responsibilities

Ensures the reliable, accurate and timely collection of data components for the program through effective utilization of the Electronic Medical Record (EMR).
Identifies cath lab patients for inclusion in the program registry through the application of strict program inclusion/exclusion criteria.
Demonstrates applicability of the methodology and the reliability of definitions utilized by reviewers within the program.
Identifies areas for streamlining and process improvement in the data collection and cardiac cath lab process.
Maintains compliance with federal, state and regulatory body laws and regulations.
Monitors other quality indicators and efficiency measures identified outside what is required for NCDR.

Education

Graduate of an accredited school of nursing required. Bachelor’s in Nursing preferred.

Work Experience

Three (3) years’ experience in inpatient cath lab nursing preferred. Quality improvement and patient safety knowledge is preferred.

Certification/License

Current RN license in the State of Missouri or Compact Licensure.

Mental/Physical Requirements

Considerable mental concentration for sustained periods of time with frequent interruptions. Light lifting (15 lbs.) required. Standing, sitting and walking required.

Working Conditions

Typical office conditions with noise and distractions. Possible eye strain or other discomfort from constant use of computer screens.

At Phelps Health, we think we have a better team, benefits, and opportunities for growth than anyone else around, and we invite you to see for yourself! Apply now to join us on our mission in health care.

Share this job

Related Jobs

Other

NURSE (Clinical/Emergency Department)

Defense Health Agency (DHA) FT LEONARD WD, MO

Overview NURSE (Clinical/Emergency Department) Fort Leonard Wood, Missouri is home of the U.S. Army Maneuver Support Center of Excellence, Army Chemical, Biological, Radiological, and Nuclear School, Army Engineer School, and U.S. Army Military Police School. Fort Leonard Wood trains and educates nearly 90 thousand troops a year. Surprisingly, the Fort also trains Marines, Airmen, Sailors, Coast Guardsmen and international students from allied nations. With more than 22,000 military members and their families, Ft Leonard Wood provides us with a diverse and well skilled population. Fort Leonard Wood, situated in the heart of the Ozark Mountains, is a sportsman’s paradise with some of the most beautiful scenery, hosting many large lakes, rivers, streams, and forests ideal for fishing and hunting. Fort Leonard Wood covers more than 61,000 acres located in Pulaski County with a population of nearly 52,607. Bordering the installation to the north are the towns of Waynesville and St. Robert, with an estimated combined population of 9,170. The installation is situated between St Louis and Springfield, Missouri 1 ½ to 2 hours respectively. Also 30 minutes equidistant between Rolla and Lebanon along I-44. It is also a great place to raise a family along with a low cost of living. Working for the Department of Defense comes with an abundance of benefits and perks to include competitive compensation packages, paid-time off, medical benefits, student loan repayments, and retirement package with Thrift Savings Plan to include matching employer contributions. For more information, please visit the following link: https://www.usajobs.gov/Help/working-in-government/benefits/ Responsibilities MAJOR DUTIES: 1. Provides Emergency Department (ED) clinical nursing care to patients of any age group. Performs triage, while considering both physical and psychosocial elements. Must quickly assess incoming patients and prioritize patient care based on need, available staffing, and patient acuity. Works as part of a team in the ED and independently manages basic life support needs and stabilizes patients until the physician or provider is available, based upon professional nursing standards and protocol. Provides comprehensive nursing care to patients presenting for urgent or emergent care using knowledge of professional nursing theories, principles, and procedures; knowledge of clinical skills to provide specialized services to patients; knowledge of emergency and resuscitative measures; knowledge of triage; knowledge of pharmaceuticals sufficient to mix and administer special, potent, and potentially lethal drugs. Observes, monitors, and assesses patient's condition; recognizes, identifies, and interprets serious situations; determines and implements proper emergency measures; performs various pulmonary ventilation functions; operates and monitors highly complex technical equipment, (e.g. cardiac monitors, ventilators, various intravenous infusion pumps, and defibrillators) and documents appropriately in the health record. Independently reacts to emergencies, collaborates with physician, makes changes in nursing care plans, assesses patient's condition, and implements nursing care plans. Teaches, onboards, and mentors professional and paraprofessional nursing staff, assisting with complex nursing and diagnostic procedures. Responds to all emergencies during the shift. Responsible for advanced cardiac life support code team management until arrival of physician or provider. Team teaches advanced clinical skills and monitors junior nursing personnel multiple phases of instruction. Continuously observes for safety hazards ensuring immediate action to resolve/correct. Acts as facilitator to mediate complaints and concerns of patients, family members and staff, taking immediate action to resolve or refer to a higher authority. Interviews and takes medical histories, to acquire medically necessary information to assess physical and mental status of patient. Collects current symptoms, as well as a detailed patient history, and then consults and coordinates with health care team members to assess, plan, implement and evaluate patient care plans. Initiates patient education plan. Teaches patients and significant others how to manage their illness/injury, by explaining: subsequent inpatient plan, post-treatment home care needs, diet/nutrition/exercise programs, self-administration of medication and rehabilitation, as well as explanation of referrals to other healthcare professionals for follow-up treatment. Provides evidence-based instructions and education to patient/significant other and/or family members/caregivers. Performs adapted patient teaching with patients requiring special approaches or preferences and documents education provided. Serves as a resource person for nurses and other health care providers to consult when particularly difficult problems in the care of patients arise. Serves as role model to experienced emergency and other nurses as well as those who are not fully trained. Provides guidance and leadership to other professional nurses and paraprofessional personnel, assisting with complex nursing and diagnostic procedures. Provide orientation and on-the-job training for such personnel. 2. Manages the delivery of nursing care for weekend, holidays, training holidays and day/evening or night shifts using knowledge of an extensive range of professional nursing theories, principles, and procedures. Identifies and recommends strategies to improve nursing unit organization, functions. Manages the delivery of nursing care, utilizing knowledge of an extensive range of professional nursing theories, principles, and procedures. Functions as a charge nurse on a rotational bases and determines staffing requirements/mix and appropriateness of bed utilization based on analysis of patient acuity data; plans, delegates, and directs nursing care based on patient care requirements and staff skill levels; evaluates and modifies plan of care based on continuous assessment of patient needs and expected outcomes; collaborates with providers to facilitate the appropriate medical management of patients; and effectively directs patient care and unit activity. Consults with the supervisor and jointly shares in decisions; resolves most conflicts, and coordinates with other team members. 3. Conducts and participates in the development, implementation, coordination, and evaluation of facility, departmental, or unit-based programs. Continuously evaluates procedures/practices occurring in the emergency department to ensure quality patient care, recommending changes or implementation of nursing service policies and procedures when applicable. Recommends strategies to improve nursing unit organization and functions utilizing evidence-based practice (EBP). Work will influence policy and procedural documents in accordance with national standards, best practices, and emerging evidence. Identifies, implements and/or monitors quality and, process assurance/improvements, and EBP. Initiates action to improve the delivery of patient care; interprets and ensures compliance with established policies, procedures, and standards of care and practice; coordinates and collaborates with interdisciplinary team to develop strategies to improve services; etc. Participates in continuing education programs to update and/or maintain skills and knowledge to meet annual requirements. Participates in department and unit-level simulation/emergency drills, staff meetings, in-services/briefings, and in continuing quality and process improvement measures. Uses current research findings and other evidence to expand professional knowledge, enhance role performance, and increase knowledge of professional emergency nursing. Completes all training requirements designated by facility, supervisor, DHA, or accrediting agencies; participates in continuing education programs to update and/or maintain skills and knowledge to meet licensing requirements. PERFORMS OTHER DUTIES AS ASSIGNED. Qualifications Who May Apply: US Citizens Basic Requirement :Degree: A graduate or higher level degree, bachelor's degree, associate degree, or diploma from an accredited professional nursing educational program is required. This education must have been accredited by the Commission on Collegiate Nursing Education, Council on Accreditation of Nurse Anesthesia Educational Programs, Accreditation Commission for Midwifery Education, or an accrediting body recognized by the U.S. Department of Education at the time the degree was obtained. (Note: You must attach a copy of your transcripts.).Licensure: A current, active, full, and unrestricted license or registration as a professional nurse from a State, the District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States; and you must have passed the National Council Licensure Examination.Foreign Degree: A degree from a Foreign Nursing School. Official certification from the Commission on Graduates of Foreign Nursing Schools is required for individuals who graduated from foreign nursing schools.

Utilization Review

Full-time

Utilization Review Registered Nurse, Care Coordination, Bethesda East, FT, 01P-11:30P Local REMOTE

Baptist Health South Florida Boynton Beach, FL

Baptist Health is the region’s largest not-for-profit healthcare organization, with 12 hospitals, over 28,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 25 years, we’ve been named one of Fortune’s 100 Best Companies to Work For, and in the 2024-2025 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 45 high-performing honors. What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients’ shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we’re all in. Description: Increases patient throughput to the most appropriate level of care while facilitating interdisciplinary care across the continuum while maintaining regularity compliance. The role Integrates, coordinates care facilitation throughput while working in partnership with the healthcare team. Is accountable for prioritizing, reviewing cases to determine the appropriateness of pre-admission, admission utilizing payer established criteria Assisting in identifying appropriate patient status and level of care. Identify readmissions managing per policy. Identify possible inappropriate hospitalizations and collaborate with the healthcare team to facilitate alternate Level of Care. Assist in identifying physician and staff documentation opportunities to support Quality and Pay for Performance indicators. Estimated salary range for this position is $73860.80 - $96019.04 / year depending on experience. Qualifications: Degrees: Associates. Licenses & Certifications: ACMA ACM Certification. CDMS Certified Disability Management Specialist. ACMA Case Management Administrator Certification. NACCM Care Manager Certified. ABMCM Certified Managed Care Nurse. RNCB Certified Rehabilitation Registered Nurse. ANCC Nursing Case Management. NBCC Certification in Continuity of Care, Advanced. Registered Nurse. CCMC Case Manager. Additional Qualifications: RNs hired prior to 10/1/2017 with an Associate Degree are not required to have a BSN to continue their non-leadership role as an RN, however, they are required to complete the BSN within 3 years of job entry date. A Case Management Certification required within 12 months of hire. 3 years of hospital clinical experience with a minimum of 1-3 years of hospital or payor Case management or Utilization management review experience preferred. Excellent interpersonal communication and negotiation skills. Strong analytical, data management and computer skills. Current working knowledge of discharge planning, utilization management, case management and performance improvement preferred. Understanding of pre-acute and post-acute venues of care and post-community resources preferred. Strong organizational and time management skills. Ability to work independently and exercise sound judgment. Ability to prioritize and manage multiple high-risk, complex patients. Ability to work with multiple members of a care team and maintain positive working relationships. Demonstrate the ability to solve problems in a fast-paced environment. Minimum Required Experience: BSN Required 3 Years of acute care experience required 1 year of Utilization Review experience required EOE, including disability/vets

Utilization Review

Full-time

Utilization Review Case Manager, RN | Case Management, Full-Time, 1st Shift (Includes every other weekend rotation)

Memorial Health (OH) Marysville, OH

We are looking for a Utilization Review Case Manager to join our collaborative team at Memorial Health! What You'll Do: Clinical/Technical Recognizes, interprets, documents, and communicates information necessary for quality patient care and related patient information. Always maintains confidentiality to protect patient’s privacy and maintains Health Insurance Portability and Accountability Act (HIPAA) privacy and security regulations. Carries out the hospital utilization review plan. Collaborates with the interdisciplinary team and asks clarifying questions regarding documentation, hospital course, and expected date of discharge. Provides clinical information to the payer as requested to obtain admission authorization and to support level of care. Communicates payer resources available for discharge planning to Case Management Team. Understands in-network coverage and out of network insurance coverage and impact on patients served. Communicates information to patient upon request. Coordinates with Patient Financial Services on all patients, including those without insurance coverage to obtain Hospital Care Assurance Program (HCAP) and Medicaid eligibility. Daily Responsibilities: Reviews charts for medical necessity and assists on the level of care and status determinations. Utilizes Evidenced Based Criteria Set (Interqual, Milliman, etc) to assess medical necessity, appropriateness of admission, level of care, length of stay, need for continued stay, and avoidable days or delays in patient care. Will provide suggestions to the ED provider and Admitting Hospitalist of the most appropriate admission status based on the patient’s expected length of stay, application of standard of care criteria, patient presentation and treatment plan of care. Will assist providers to clearly and completely document for the purpose of accurately representing the acuity of the patient. Formulates and documents clinical review and submits clinical information to payer as required per departmental policy. Has knowledge of expected length of stay based on established criteria, ensures payer response to authorization requests are obtained for hospital services and documents authorization in auth/cert fields in Epic based on payer responses. Accesses payer portals daily to submit clinical review, appeal letters and obtain authorization numbers. Documents activity in Epic UR comment and communication field. Utilizes physician advisor services in accordance with hospital/department policy for secondary review consideration. Collaborates with presurgical scheduler to monitor the surgery schedule daily for prior authorization of inpatient procedures and monitoring for Medicare FFS inpatient only procedure status confirmation. Assumes responsibility for the oversight of inpatient medical necessity denials: track, monitor, investigate, and report denials and outcomes through participation in the Denials Management Committee and per request investigate root cause analysis or other information. Appropriately document and generate timely appeal letters and submit to payers for denial reconsideration. Manage work queues as assigned by Director or Supervisor. Including tracking and tending results. Calls payer UR nurse and requests reconsideration of a potential concurrent denial via conversation with insurance UR nurse reviewer prior to accepting a concurrent denial. Generates timely and thorough appeal letters in response to an inpatient denial and submits via the payer requested methodology. Manage the workflow through the appropriate work queues and determines case review based on timeliness of the appeal and high dollar amount. Facilitates the Peer-to-Peer denial/appeal process and proactively communicate with payer for denials mitigation and prevention. Appropriately monitor the outcome and document the process in Epic. Provides written notices (following the documentation retention policy) to the Medicare Beneficiary, including but not limited to: Hospital-Issued Notice of Non-Coverage (HINN) Detailed Notice of Discharge Advance Beneficiary Notices Denial letters if applicable Coordinates with Livanta, Permideon (or other organizations) and medical team for patient denials and requests for additional information for inpatient stays. Follows policy/procedure maintaining regulatory compliance and documentation retention requirements. Maintains a current knowledge of rules and regulations surrounding utilization management; observation management, and payer methodologies including approvals, denials, and appeal processes. Maintains a current knowledge of revised rule/regulatory changes pertaining to utilization review, strategies to reduce and combat denials, and effective care transitions management. Collects and interprets data as designated by the Utilization Review Committee, Denials Committee, and the department Key Results Measures including, but not limited to outlier review, readmission analysis, observation management, extended stay reviews, denials root cause analysis, and other reporting as assigned. Acts as a resource for staff; including Providers, agency and contingent personnel. Interpersonal Communicates in order to educate patients/ family; provides kindness and consideration in meeting the emotional needs of patients; confers with Providers and Case Management Team, interacts with ancillary staff. Provides excellent customer service, facilitates quality care delivery and fosters an atmosphere of understanding cultural diversity. Communicates and assists providers as indicated. Must have excellent written, verbal and telephone communication skills. All interactions are conducted in a professional manner. Demonstrates a positive attitude. Resolves conflict through one-on-one negotiation or with the assistance of Director or designee. Demonstrates the philosophy of team concept. Participates in unit projects, attends committees as assigned, and attends monthly staff meetings. Communicates dissatisfaction with issues to Director; actively contributes to the solution of problems and refrains from promoting dissatisfaction among co-workers. Critical Thinking Actively looks for and creates opportunities to improve the department, staff, and personal development. Develops and demonstrates knowledge of current developments in field to maintain professional competency. Compliant with CMS, DNV, Federal, State, hospital and departmental policies and procedures. Follows the Ohio Nurse Practice Act Understand the importance of Utilization Review and how job functions, impacts the revenue cycle, compliance, patient finances, and patient satisfaction. Documentation Maintains accurate data collection and timely documentation. Documentation retention practices are followed per hospital and department policy. Refrains from using unaccepted abbreviation in written documentation. When necessary, follows department downtime procedures Maintains license Enters and retrieves information from computer; demonstrated competence in the electronic medical record, Microsoft/Outlook/Word/Excel, other software tools and portals as assigned. Unit Financial Accountability Understands and is accountable to hospital goals and benchmarks for financial viability Is accountable for productivity and time management Maintains appropriateness of supplies Education Completes all mandatory education and in services required for the facility Completes an initial orientation and competencies per Human Resources established guidelines Completes annual competencies and unit specific competencies per Human Resources established guidelines Maintains professional competency; actively contributes to the solution of problems; deals with problems involving several variables within familiar context Responsible and accountable for maintaining own state board required CEU’s per licensing board requirements. Has knowledge of HIPAA privacy regulation and related procedures Has knowledge of Centers for Medicare and Medicaid Services and third party in network payer updates on benefit coverage and acute care policies Reviews Case management literature as distributed by director or designee Maintains bi-annual BLS certification. Completes mandatory health requirements (e.g. annual TB testing, Fit testing and physicals as indicated.) Attendance Demonstrates regular and predictable attendance Work scheduled holidays and weekends Overtime to be pre-approved per Director Requested schedule time off to be pre-approved by Director or designee Other Exhibits behaviors reflective of Memorial’s core values: Compassion, Accountability, Respect, Excellence, and Service Attends all mandatory education and in-services (i.e., team training, safety, infection control, etc.); completes mandatory health requirements. Employee performs within the prescribed limits of the hospital’s and department’s Ethics and Compliance program and is responsible to detect, observe and report compliance variances to their immediate supervisor, or upward through the chain of command, the Compliance Officer, or the hospital hotline. Works assigned shift hours, may be asked to rotate hours or shifts if needed or upon the Director's request/discretion, to maintain adequate department coverage including weekend and holiday rotation. Performs reviews as assigned across multiple access points into the hospital and manages both inpatient and outpatient care areas as they relate to the UR function. Performs other duties as assigned. Requirements Completion of an accredited school of nursing with current active registration in the State of Ohio as an RN or LPN in good standing. Must have at least two years of clinical nursing or case management experience. Completes the required 24 contact hours of approved CE during each two year renewal period consistent with the Ohio Board of Nursing requirements. Maintains continuous certification in American Heart Association’s BLS. Shift 1st (Includes every other weekend rotation) Hours 80 per pay (Every two weeks) Benefits • Medical Insurance • Dental Insurance • Vision Insurance • Life Insurance • Flexible Spending Account Time Off • Vacation • Sick Leave • 11 Paid Holidays • Personal Day Retirement • Ohio Public Employee Retirement System • Deferred Compensation Other • Tuition Reimbursement • Kidzlink Daycare Center • Employee Recognition • Free Parking • Wellness Center • Competitive Salaries • Community/Family Atmosphere We look forward to seeing your application! It is our commitment to inclusivity and diversity and our ongoing determination to provide a welcoming and inclusive environment for all staff and guests of the Hospital, regardless of age, color, disability, gender, gender expression or gender identity, genetic information, national origin, race, religion, sexual orientation, or veteran status. For any questions or needed accommodations, please contact Memorial Health Human Resources at 937.578.2701.

Utilization Review

Full-time

Utilization Review Registered Nurse, Case Management, PT, 08A-4:30P Local Remote

Baptist Health South Florida Boca Raton, FL

$35.51 - $46.16 / hour

Baptist Health is the region’s largest not-for-profit healthcare organization, with 12 hospitals, over 28,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 25 years, we’ve been named one of Fortune’s 100 Best Companies to Work For, and in the 2024-2025 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 45 high-performing honors. What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients’ shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we’re all in. Description: The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention, coordination to decrease avoidable delays, denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry. Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians. Identify opportunities for expedited appeals and collaborates to resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments. Estimated salary range for this position is $35.51 - $46.16 / hr depending on experience. Qualifications: Degrees: Associates. Licenses & Certifications: MCG Care Guidelines Specialist. Registered Nurse. Additional Qualifications: RNs hired prior to 2-2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN. however, they are required to complete the BSN within 3 years of job entry date. MCG Specialist Certification ISC/HRC required within 12 months of job entry date. 3 years of Nursing experience preferred. Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical/chart review abstract information efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Current working knowledge of payer and managed care reimbursement preferred. Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families. Knowledgeable in local, state, and federal legislation and regulations. Ability to tolerate high volume production standards. Minimum Required Experience: 3 Years of Nursing experience required EOE, including disability/vets

Utilization Review

Full-time

Registered Nurse Utilization Review

Ascension Austin, TX

$78,561.60 - $110,905.60 / year

Your future role at a glance Location: Remote Facility: Dell Children's Medical Center - Austin Department: Utilization Management Schedule: Days l Full-time Salary range: $78,561.60 - $110,905.60 per year #UM2026 Life at Ascension: Where purpose meets opportunity Ascension is a leading nonprofit Catholic health system with a culture and associate experience grounded in service, growth, care and connection. We empower our 99,000+ associates to bring their skills and expertise every day to reimagining healthcare, together. Recognized as one of the Best 150+ Places to Work in Healthcare and a Military-Friendly Gold Employer, you’ll find an inclusive and supportive environment where your contributions truly matter. Benefits that help you thrive Comprehensive health coverage: medical, dental, vision, prescription coverage and HSA/FSA options Financial security & retirement: employer-matched 403(b), planning and hardship resources, disability and life insurance Time to recharge: pro-rated paid time off (PTO) and holidays Career growth: Ascension-paid tuition (Vocare), reimbursement, ongoing professional development and online learning Emotional well-being: Employee Assistance Program , counseling and peer support, spiritual care and stress management resources Family support: parental leave, adoption assistance and family benefits Other benefits: optional legal and pet insurance, transportation savings and more Benefit options and eligibility vary by position, scheduled hours and location. Benefits are subject to change at any time. Your recruiter will provide the most up-to-date details during the hiring process. How you’ll make an impact in this role Evaluate medical necessity for admissions and service requests to ensure patients receive the most appropriate care at the right time. Lead the discharge planning process by collaborating with the healthcare team to create seamless transitions and safe returns home for patients. Navigate complex case management scenarios, providing expert consultation to resolve barriers to care and optimize patient outcomes. Ensure full compliance with federal and third-party regulations, protecting the integrity of our clinical services and reimbursement processes. Resolve documentation and reimbursement challenges to support the department in reducing claim denials and improving operational efficiency. What minimum requirements you’ll need Licensure / Certification / Registration: Licensed Registered Nurse credentialed from the Texas Board of Nursing or current home state license for multi-state license recognition "Compact State" obtained prior to hire date or job transfer date required. Education: Diploma from an accredited school/college of nursing OR Required professional licensure at time of hire. What additional preferences we're seeking Pediatric Utilization Management experienced required. Clinical Licensure: Active and unrestricted Registered Nurse (RN) license or equivalent clinical credential required for medical necessity determination. Compact or TX state license required. Utilization Management Expertise: Proven experience applying medical necessity criteria (such as InterQual or Milliman) within a clinical or payer environment. Equal employment opportunity employer Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws. For further information, view the EEO Know Your Rights (English) poster or EEO Know Your Rights (Spanish) poster. Fraud prevention notice Prospective applicants should be vigilant against fraudulent job offers and interview requests. Scammers may use sophisticated tactics to impersonate Ascension employees. To ensure your safety, please remember: Ascension will never ask for payment or to provide banking or financial information as part of the job application or hiring process. Our legitimate email communications will always come from an @ascension.org email address; do not trust other domains, and an official offer will only be extended to candidates who have completed a job application through our authorized applicant tracking system. E-Verify statement Employer does not participate in E-Verify and therefore cannot employ STEM OPT candidates.