Emergency Prospective Review RN

Texas Connect, Inc. (TCI) is a Management Services Organization (MSO). ‍ As an MSO, we are dedicated to providing business and administrative services for healthcare providers, such as medical practices and hospital systems, allowing them to focus on patient care. TCI handles crucial backend functions, such as Information Technology, Billing, and Medical Coding. This allows our client healthcare organizations to delegate these and other essential, but non-medical tasks to TCI to improve operational efficiency. https://www.texasconnectinc.com

This position is open to Texas residents ONLY. We're hiring for 3 shifts, 7am, 7md, 7pm.

The Emergency Prospective Review (EPR) RN has the responsibility to conduct a review of all patients requiring hospital admission from the emergency room at all facilities after stabilizing care has been initiated for medical necessity and appropriateness. Also, the EPR-RN is responsible for reviewing all interfacility transfer request from non-PIH facility in accordance to transfer policies, Health and Safety Codes, and applicable laws (COBRA/EMTALA). The EPR-RN performs, and supervises the EPRN-LVN, in utilization review with a prominent level of expertise by using approved criteria that demonstrates medical necessity to achieve appropriate authorization and reimbursement for services for the appropriate level of care and status (Inpatient, Observation, or Outpatient). EPR-RN Communicates medical necessity criteria effectively to outside insurance providers to obtain appropriate authorization for services up front or engages in disagreement of care in accordance with Health and Safety Codes. Additionally, EPR-RN collaborates closely with patient’s insurance and various payors to coordinate and assist with reparation/transfer of out-of-network patients from PIH facility to the patient’s contracted facility including coordination of post-emergency discharge needs, as necessary. EPR-RN is also responsible for the repatriation of all PHP risk patients from non-PIH facilities to any one of the PIH facilities in an expeditious manner. EPR-RN conducts emergency physician-to-emergency physician discussions of members and provides authorization for post-stabilization care of PHP members presenting at a non-PIH facility and is required to assist in making other appropriate arrangements to promote/enhance continuity of care. Similarly, EPR -RN is responsible for the issuance of post stabilization care (PSC) denial to facilities and providers who fail to meet requirements in accordance with Health and Safety Codes. Lastly, the EPR-RN Works collaboratively with House Supervisor or designee in ensuring timely bed assignment and placement of patient admissions or transfers from PIH ED or outside facility. The position serves as a liaison between patients, families, providers, payors, and PIH Health leadership to optimize resource utilization and patient outcomes. This position is considered hybrid with remote and in-office assignment.