RN Utilization Management Care Reviewer

This is a fully remote position, open to applicants in Arizona.

📋 Description

• Evaluate inpatient services to guarantee optimal results, cost efficiency, and adherence to state and federal regulations and guidelines.

• Assess clinical services based on evidence-based guidelines.

• Determine appropriate benefits, eligibility, and anticipated length of stay for requested services, treatments, and procedures.

• Conduct inpatient reviews to assess financial responsibility.

• Carry out authorization reviews and related tasks as necessary.

• Process requests within specified timelines.

• Refer suitable cases to Medical Directors and present them consistently and efficiently.

• Make appropriate referrals to other clinical programs.

• Collaborate with multidisciplinary teams to enhance Banner Health’s Integrated model.

• Communicate with providers, members, and internal and external service teams to gather information and convey determinations.

• Manage length of stay, discharge planning, and resources effectively.

• Identify potential quality-of-care or safety issues.

• Comply with Utilization Management policies and procedures.

⛳️ Requirements

• Bachelor’s degree in nursing or equivalent practical knowledge.

• Active, unrestricted State Registered Nursing (RN) license in good standing.

• MCG certification or the ability to obtain it within six months of employment.

• Five years of clinical nursing experience or equivalent practical knowledge.

• High proficiency in computer usage, typing, and Microsoft Suite.

• Capability to navigate multiple platforms.

• High proficiency in medical record review, including EMR and paper/fax platforms.

• Two to three years of Utilization Management experience utilizing 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.

• Familiarity with URAC and NCQA accreditation processes 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.