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.

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.

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).

• 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.