Job Description

Registered Nurse RN Utilization Management Care Reviewer Remote Location Remote in Phoenix, AZ :

Primary City/State: Arizona, Arizona

Department Name:

Utilization Mgmt

Work Shift:

Day

Job Category:

Clinical Care

Find your path in health care. At Banner Health, caring for people is at the core of all we do. We are committed to diversity, equity and inclusion. If that sounds like something you want to be a part of - apply today!

Arizona is a year-round destination. Sunny skies and low humidity prevail 300 days a year across the state. From awesome natural wonders to culinary treats, tribal lands, vibrant cities, world-class resorts, renowned golfing and historic Western towns, there are some truly breathtaking moments to be had in the Grand Canyon State.

As an RN Utilization Management Care Reviewer, you will be an important part of the Banner Plans & Networks Team. This 100% remote role manages a typical caseload of 20-25 members at a time with a minimum of one clinical review every seven days. You will work autonomously in this heavily compliance driven role. You will call upon your critical thinking and problem-solving skills, utilize a variety of resources, and collaborate with multiple departments including Claims. The schedule for your role will be Monday-Friday, 8:00 a.m.-5:00 p.m. This 100% remote role does require Arizona residency for regulation compliance. If this role sounds like the one for you, Apply Today!

Banner Health Network (BHN) is an accountable care organization that joins Arizona's largest health care provider, Banner Health, and an extensive network of primary care and specialty physicians to provide the most comprehensive healthcare solutions for Maricopa County and parts of Pinal County. Through BHN, known nationally as an innovative leader in new health care models, insurance plans and physicians are coming together to work collaboratively to keep members in optimal health, while reducing costs.

POSITION SUMMARY This position, within the Utilization Management Department, will determine the medical appropriateness of requested services by reviewing clinical information and applying evidenced-based guidelines. This position will interact with providers, members, internal and external service teams to obtain necessary information and communicate determinations. In addition to pre-service, admission, and concurrent review determinations, this position will be responsible for managing length of stay, discharge planning, resources, and identification of potential quality of care or safety concerns. CORE FUNCTIONS 1. Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness, and compliance with all state and federal regulations and guidelines. 2. Analyzes clinical services from members or providers against evidence-based guidelines. 3. Identifies appropriate benefits, eligibility, and expected length of stay for requested services, treatments, and/or procedures. 4. Conducts inpatient reviews to determine financial responsibility. May also perform authorization reviews and/or related duties as needed. Processes requests within required timelines. 5. Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner. Makes appropriate referrals to other clinical programs. 6. Collaborates with multidisciplinary teams to promote Banner Health's Integrated model. 7. Adheres to UM policies and procedures. MINIMUM QUALIFICATIONS

Bachelor's degree in nursing or equivalent working knowledge. Active, unrestricted State Registered Nursing (RN) license in good standing. MCG certification or ability to obtain within six months of hire. Five years of clinical nursing experience or equivalent working knowledge. Must be highly proficient with computer usage, typing, Microsoft Suite, and possess the ability to navigate through multiple platforms. Must be highly proficient in medical record review including EMR and paper/fax platforms. PREFERRED QUALIFICATIONS

Two to three years of Utilization Management experience using MCG, CMS, and clinical criteria. MSN preferred. Case Management Certification (CCM or RN-BC or CMCN). Utilization Management Certification. Certified Professional in Healthcare Quality Certification (CPHQ). Experience with Medicare Advantage, ACOs, Commercial, Dual Eligible, AHCCCS, and/or ALTCS. Experience with URAC and NCQA accreditation process. Experience using Medical Management software platforms. Additional related education and/or experience preferred.

EOE/Female/Minority/Disability/Veterans

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Job Tags

Full time, Shift work, Monday to Friday,

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