The Utilization Management Nurse utilizes sound clinical judgment and established criteria for guidance in conducting clinical reviews for appropriate admissions and continued stays. Further reviews include the appropriateness of care delivered in accordance with Joint Commission and other regulatory standards and services throughout the continuum of care and focused reviews of utilization patterns.

Duties

Major Duties (To include but not limited to): 1. Provides consultative guidance, standardized resources, and targeted education to determine medical necessity of inpatient Veteran healthcare through application of evidence-based criteria. 2. Functioning as an inpatient care coordinator, working across care settings, contacting health care providers and other services pertaining to patient flow. 3. Performing reviews and documenting in NUMI at a minimum, 80% of acute inpatient assigned to them of admissions, observation stays and subsequent days of care. 4. Performing daily continued-stay reviews, no later than the first business day following weekends or holidays. 5. Demonstrates leadership for improvement of patient care outcomes using standards of care, scientific evidence, and practice to effect positive outcomes of inpatient Admissions and Continued Stays. 6. Systematically evaluates UM processes and provide recommendations for performance improvement within area of expertise. 7. Attends and participates in programs, committees, and/or services that relate to care and utilization management {UM Subcommittee, QPS and UM Staff meetings and Huddles). 8. Provides monitoring of clinical documentation to ensure NUMI compliance. 9. Provides timely, reliable, and accurate feedback and education to clinical leadership and clinical staff on criteria findings. 10. Provides education to all levels of the organization on UM processes. 11. Consults with providers and multi-disciplinary teams on the clinical appropriateness criteria information and recommend Level of Care (LOC) and may refer specific cases to Physician Utilization Management Advisors (PUMA). 12. Participates in annual criteria training; annual testing for applying and interpreting lnterQual? criteria within 60 days of annual criteria release. 13. Perform Inter-rater Reliability (IRR), a performance tool that measures consistency in the application and interpretation of standardized criteria among UM reviewers, assessments as assigned by the UMPD. 14. Strives to maintain an IRR 90% or greater level of agreement in the primary outcome measure of either meeting or not meeting the lnterQual? criteria for observation, admission or continued stay reviews. VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary, regular salary increases, potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Licensure: 1 full and unrestricted license from any US State or territory Work Schedule: 0730am - 0400pm; Monday - Friday; may be required to work up to 6:00pm, according to the needs of the service. Telework: 100% Remote within local commuting area; must be willing to relocate within the commuting area of Michael E. DeBakey VA Medical Center. Remote: Will be required to report in to the facility during the year. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required

Requirements

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. In accordance with 38 U.S.C. 7402(d), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Graduate of a school of professional nursing approved by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE). The approving official may authorize a waiver of the requirement for ACEN or CCNE accreditation of any degree in nursing provided the college or university has regional accreditation from an accrediting body recognized by the Department of Education at the time of the candidate's graduation and the composite qualifications of the applicant warrant such consideration. In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (Reference VA Handbook 5005, Appendix G6) OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing. Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia. Preferred Experience: 1-3 years Utilization Management, Nurse Case Manager/Caseworker, and/or Process Improvement Consultant Experience. 3-5 years of experience in inpatient acute, psychiatric and/or critical care healthcare settings. Knowledge and ability to apply InterQual criteria, utilization management processes, clinical documentation requirements, currents standards of care, and compliance guidelines. Knowledge and ability to apply principles of evidence-based practice. Proficiency in excel and other Microsoft Office software applications. Experience in data analyses, visualization, and evaluation. Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade: Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required. Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience. Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience. Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 years of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 years of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required. Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 years of nursing practice/experience; OR a Doctoral degree and approximately 2-3 years of nursing practice/experience. Note regarding MSN degrees: If your MSN was obtained via a Bridge Program that qualifies for professional nursing registration, a BSN is not required. Reference: VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard. This can be found in the local Human Resources Office. Physical Requirements: This position requires visual acuity (including depth perception), keen hearing (aide permitted), clear distinctive speech and manual dexterity in both hands. This position requires potentially long periods of continued walking (2-4 hours), standing (2-6 hours), stooping, sitting, bending, pulling (1-2 hours) and pushing (1-2 hours), lifting (greater than 50 pounds), carrying (greater than 50 pounds). Transferring patients and objects may be required. Mechanical inpatient lifts are provided. The incumbent may be exposed to infected patients and contaminated materials and may be required to don protective clothing in isolation situations, operative/invasive procedures, or home settings. The incumbent may be exposed to patients who are combative secondary to delirium, dementia, or psychiatric disorders. Ability for rapid mental and muscular coordination simultaneously. The incumbent must be a mature, flexible, sensible individual capable of working effectively in stressful situations, able to shift priorities based on patient needs. Must complete annual Employee Health requirements, such as annual TB screening or testing, as a condition of employment. Must be able to work closely with others, as well as protracted or irregular hours of work. Must be compliance with the use of ergonomic exercises and employee safety requirements. The incumbent who provides care in home settings or other off-site locations may be required to drive and/or ride in GSA-vehicles.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

Contacts

• Address Michael E DeBakey VA Medical Center 2002 Holcombe Boulevard Houston, TX 77030 US
• Name: Ann Martin
• Phone: 210-617-5300
• Email: [email protected]