RN Utilization Management Care Reviewer

Department Name: Utilization Mgmt Work Shift: Day Job Category: Clinical Care Additional Job Description Better Than Ever for Nurses. When we make things better than ever for nurses at Banner Health, we make things better than ever for all of us. This means investing in the holistic health and happiness of our nurses—through better pay, better benefits, better opportunities and a better community. As a Registered Nurse RN Utilization Management Care Reviewer, you will be working in partnership with the Medical Director, to evaluate patient care, conduct reviews, and identify issues that may delay patient services, to ensure exceptional care is being delivered. You will collaborate with Ambulatory Case Management and Facility Case Managers to ensure safe and proper coordination upon discharge from facilities. Candidates must have critical care experience (ICU/ER/flight/PACU). Must be able to work independently and have basic knowledge of EMRs and the Microsoft platform. A strong comfort level with computers, basic IT skills, and a reliable internet connection is also required. The Registered Nurse RN Utilization Management Care Reviewer position is a fully remote position with a work schedule of Monday - Friday 8am - 5pm. Candidates must live in the state of AZ to be considered. Your pay and benefits (Total Rewards) are important components of your Journey at Banner Health. Banner Health offers a variety of benefit plans to help you and your family. We provide health and financial security options, so you can focus on being the best at what you do and enjoying your life. Banner Plans & Networks (BPN) 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 BPN, 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. Estimated Pay Range: $37.14 - $61.90 / hour Banner Health is committed to pay equity and transparency. The posted compensation range is a reasonable estimate that extends from the lowest to the highest pay Banner Health in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. This range is based on possible base salaries and does not include the value of our total rewards package. Actual pay determined at offer will be based on years of relevant work experience, education, certifications, skills, and geographic location, along with a review of current employees in similar roles to ensure pay equity is achieved and maintained. EEO Statement: EEO/Disabled/Veterans Our organization supports a drug-free work environment. Privacy Policy: Privacy Policy