Description

*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. *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: * Eligibility on day 1 for all benefits * Dollar-for-dollar 401(k) match, up to 5% * Debt-free tuition assistance, offering access to many no-cost and low-cost degrees, certificates and more * Immediate access to time off benefits At Baylor Scott & White Health, your well-being is our top priority. Note: Benefits may vary based on position type and/or level *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. *Schedule* * You will work primarily remote. * Will be required to work onsite at a BSW facility for quarterly meetings * Will be required to work onsite at a BSW facility if experience any technical/connection issues *Essential Functions of the Role* * 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. *Key Success Factors* * An advanced understanding of healthcare procedures, treatments, terms, conditions, and equipment. * An ability to see the world from our customers' eyes and find resolutions to fit their needs. * Proficiency in discharge planning, setting case management referral standards, reviewing utilization, and categorizing levels of care. * Excellent communication skills with a knack for expressing your thoughts clearly, whether orally or in writing. * Effective interpersonal abilities to interact positively and cooperatively with a variety of people. * Exceptional critical thinking and problem-solving skills for dealing with complex situations. * The ability to juggle multiple tasks and responsibilities while sticking to deadlines. * Proficiency in scrutinizing, understanding, and applying detailed clinical care documentation. * Computer literacy, especially in Microsoft Office and medical documentation systems. * Case management certifications, such as Certified Case Manager, are beneficial but not necessary for this position. *Belonging Statement* * We believe that all people should feel welcomed, valued and supported, and that our workforce should be reflective of the communities we serve. *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).