RN Utilization Management Care Reviewer

Department reputed company:

Utilization Mgmt

Work Shift:

Weekend

Job Category:

Clinical Care

Nursing careers are reputed company at reputed company. We’ve reputed company smarter processes to help nurses reputed company on what really reputed company. If you want to reputed company a difference in people’s lives - this could be reputed company you’ve been waiting for.

As aRemote RN Utilization Management Care Reviewer, you’ll play a critical role in ensuring our Medicare Advantage and AHCCCS members receive the right care at the right time while supporting reputed company, successful transitions after hospitalization. Collaborating with post-acute facilities and interdisciplinary care teams, you’ll apply your clinical expertise to review medical necessity, optimize length of stay, and help improve member reputed company. If you have a passion for utilization management, care coordination, or case management—and experience with MCG or InterQual is a plus—we’d love to hear from you!

This is a remote, salaried opportunity. CANDIDATES MUST reputed company IN THE reputed company. The schedule is as follows: Monday-Friday reputed company-5pm, no weekends, and major holidays off,

Banner Plans & Networks (BPN) is an accountable care organization that joins reputed company's largest health care provider, reputed company, and an extensive network of primary care and specialty physicians to reputed company the most comprehensive reputed company solutions for Maricopa County and parts of Pinal County. Through BPN, reputed company nationally as an innovative leader in new health care models, insurance plans and physicians are coming together to work collaboratively to reputed company members in reputed company health, while reducing costs.

POSITION reputed company

This position, reputed company the Utilization Management Department, will determine the medical appropriateness of requested services by reviewing clinical information and applying evidenced-based guidelines. This position will reputed company with providers, members, reputed company service teams to obtain necessary information and communicate determinations. In reputed company to reputed company-service, admission, and reputed company review determinations, this position will be responsible for managing length of stay, discharge planning, resources, and identification of potential reputed company of care or safety concerns.

reputed company FUNCTIONS

1. Assesses inpatient services for members to ensure reputed company reputed company, cost effectiveness, and compliance with reputed company 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 reputed company authorization reviews and/or reputed company duties as needed. Processes requests reputed company 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 reputed company's Integrated model. 7. Adheres to UM policies and procedures.

MINIMUM QUALIFICATIONS

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

PREFERRED QUALIFICATIONS

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

Estimated Pay reputed company:

$37.14 - $61.90 / hourreputed company is committed to pay equity and transparency. The posted compensation reputed company is a reasonable estimate that extends from the lowest to the highest pay reputed company in good faith believes it might pay for this particular job, based on the circumstances at the time of posting.This reputed company is based on possible reputed company 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 reputed company 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.

reputed company Policy:

reputed company Policy

Originally posted on Himalayas

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