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: * 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. 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. Essential Functions of the Role * Review medical services and records to determine medical necessity using established guidelines * Evaluate plan of care and confirm documentation supports appropriate level of care (plan of care) * Communicate with health plans and provider care coordination teams regarding authorizations and denials * Identify cases that do not meet criteria and coordinate next steps with relevant stakeholders * Anticipate discharge needs and support efficient transitions of care * Communicate trends, issues, and concerns to leadership * Identify quality assurance and risk management opportunities * Participate in initiatives to improve care coordination and implement evidence based practices * Support service recovery efforts to strengthen provider and member relationships Key Success Factors * Strong knowledge of healthcare procedures, treatments, terminology, and clinical documentation * Experience with utilization review, discharge planning, and levels of care determination * Excellent written and verbal communication skills * Strong critical thinking, problem solving, and organizational skills * Ability to manage multiple priorities and meet deadlines * Proficient in Microsoft Office and clinical documentation systems * Case management certification (e.g., CCM) preferred but not required Belonging Statement We believe that all people should feel welcomed, valued and supported. *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).