RN Utilization Management Care Reviewer

🔥 0 minutes ago

🌵 Arizona – Remote

🌵 Arizona – Remote

💵 $37 - $61 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

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Banner Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1999

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Banner Health is a leading healthcare system committed to making healthcare easier through comprehensive patient services and resources. They provide a safe place for care with services ranging from emergency and urgent care, imaging, and surgery centers to maternity and hospice care. Banner Health also offers telehealth options to ensure access to healthcare, regardless of location. They support athletes through Banner Orthopedics & Sports Medicine and have been recognized for exceptional patient care. With advanced digital tools, they aim to manage healthcare seamlessly for their patients.

📋 Description

• Review inpatient services to ensure optimum outcomes, cost effectiveness, and compliance with state and federal regulations and guidelines • Analyze clinical services against evidence-based guidelines • Identify appropriate benefits, eligibility, and expected length of stay for requested services, treatments, and procedures • Conduct inpatient reviews to determine financial responsibility • Perform authorization reviews and related duties as needed • Process requests within required timelines • Refer appropriate cases to Medical Directors and present them consistently and efficiently • Make appropriate referrals to other clinical programs • Collaborate with multidisciplinary teams to promote Banner Health’s Integrated model • Interact with providers, members, and internal and external service teams to obtain information and communicate determinations • Manage length of stay, discharge planning, and resources • Identify potential quality-of-care or safety concerns • Adhere to Utilization Management 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 • High proficiency with computer usage, typing, and Microsoft Suite • Ability to navigate multiple platforms • High proficiency in medical record review, including EMR and paper/fax platforms • Two to three years of Utilization Management experience using MCG, CMS, and clinical criteria preferred • MSN preferred • Case Management Certification (CCM, RN-BC, or CMCN) preferred • Utilization Management Certification preferred • Certified Professional in Healthcare Quality Certification (CPHQ) preferred • Experience with Medicare Advantage, ACOs, Commercial, Dual Eligible, AHCCCS, and/or ALTCS preferred • Experience with URAC and NCQA accreditation process preferred • Experience using Medical Management software platforms preferred • Additional related education and/or experience preferred • Candidates must reside in the State of Arizona

🏖️ Benefits

• Monday-Friday schedule, 8am-5pm • No weekends • Major holidays off • Remote work opportunity • Comprehensive benefit package for benefit-eligible positions • Pay equity and transparency • Drug-free work environment