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

As the Utilization Review RN 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.