RN Utilization Management Care Reviewer

About the role

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.

Responsibilities

• Affirms inpatient services for members to ensure optimum outcomes, cost effectiveness, and compliance with all state and federal regulations and guidelines.
• Analyzes clinical services from members or providers against evidence-based guidelines.
• Identifies appropriate benefits, eligibility, and expected length of stay for requested services, treatments, and/or procedures.
• Conducts inpatient reviews to determine financial responsibility.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote Banner Health's Integrated model.
• Adheres to UM policies and procedures.

Requirements

• 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.

Benefits

Not specified.

Pay

Estimated Pay Range: $37.14 - $61.90 / hour

Schedule

Monday-Friday 8am-5pm, no weekends, and major holidays off.