Are you an experienced RN with a strong background in hospital-based utilization review ? As a PRN Utilization Review RN, you will play an important role in supporting quality patient care by conducting thorough clinical reviews to determine medical necessity, appropriate level of care, and resource utilization. Using established clinical criteria and your nursing expertise, you will perform prospective, concurrent, and retrospective utilization reviews while partnering with physicians, care management teams, health plans, and other healthcare professionals.
Your clinical judgment and communication skills will help ensure patients receive the right care, at the right level, while supporting appropriate resource utilization and regulatory requirements. This is a hybrid PRN position requiring a commitment of at least two 8-hour shifts per month .
of the Role Conduct prospective, concurrent, and retrospective utilization reviews using established clinical criteria and evidence-based guidelines to determine medical necessity and appropriate level of care. Review patient clinical information, including diagnoses, treatment plans, services, and length of stay, to support appropriate utilization and care delivery. Evaluate and validate admission status and level-of-care determinations; collaborate with Utilization Review Coordinators and other members of the care team as needed.
Identify complex clinical or utilization issues and work collaboratively with physicians, care management teams, health plans, and other stakeholders to resolve concerns. Communicate with health plan representatives and physicians regarding medical necessity, clinical information, authorizations, and required documentation. Ensure required clinical documentation is complete, accurate, and submitted within established timeframes.
Identify and escalate payer issues, quality concerns, potential risks, and other issues requiring leadership awareness or intervention. Support discharge planning, care coordination, and appropriate transitions of care through effective utilization review practices. Participate in the evaluation, development, and implementation of utilization management processes, protocols, policies, and procedures.
Maintain compliance with applicable regulatory requirements, organizational policies, and established utilization review standards. Effectively manage multiple cases, priorities, and deadlines in a fast-paced healthcare environment. Key Success Factors Strong understanding of hospital-based utilization review and utilization management processes .
Knowledge of inpatient levels of care, medical necessity, length-of-stay management, discharge planning, and care coordination. Ability to apply established clinical criteria and guidelines to complex patient cases. Strong clinical judgment, critical thinking, and problem-solving skills.
Understanding of healthcare terminology, clinical practices, and interdisciplinary care delivery. Knowledge of applicable federal and state regulations and standards, including those associated with the Centers for Medicare & Medicaid Services (CMS), Department of Labor (DOL), Department of Insurance, Health and Human Services Commission (HHSC), and National Committee for Quality Assurance (NCQA). Excellent verbal and written communication skills, with the ability to effectively communicate with physicians, nurses, health plans, patients, and other healthcare professionals.
Strong organizational skills and the ability to manage multiple cases and competing priorities within established timeframes. Ability to work independently while collaborating effectively with a multidisciplinary team. Comfortable working in a hybrid environment and adapting to changing priorities.
Qualifications Associate degree in Nursing required; Bachelor's degree in Nursing preferred. Current, unrestricted Registered Nurse (RN) license required. Minimum of three (3) years of professional nursing experience required.
Prior hospital-based utilization review experience required. Nursing experience in an ICU, Med/Surg, or other acute-care hospital setting preferred. Experience with prospective, concurrent, and/or retrospective utilization review preferred.
Strong knowledge of medical necessity criteria, level-of-care determination, and care coordination preferred. Must be available to work at least two (2) 8-hour shifts per month in this PRN role. Ability to work effectively in a hybrid environment .
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.
Benefits Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include: Immediate eligibility for health and welfare benefits 401(k) savings plan with dollar-for-dollar match up to 5% Tuition Reimbursement PTO accrual beginning Day 1 Note: Benefits may vary based upon position type and/or level.
Belonging Statement We believe that all people should feel welcomed, valued and supported. Qualifications Associate degree. Prior experience of at least (3) three years in the nursing field.
Must have a valid nursing registration (RN).
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