Experience Inc. Jobs

Primary City/State:

Phoenix, Arizona

Department Name:

Utilization Mgmt

Work Shift:

Day

Job Category:

Clinical Care

Help move health care into the future. At Banner Health Network we are changing health care to make the experience the best it can be. If that sounds like something you want to be part of, apply today.

Banner Plans & Networks (BPN) is an integrated network for Medicare and private health plans. Known nationally as an innovative leader, BPN insurance plans and physicians work collaboratively to keep members in optimal health while reducing costs. Supporting our members and vast network of providers is a team of professionals known for innovation, collaboration, and teamwork. If you would like to contribute to this leading-edge work, we invite you to bring your experience and skills to BPN.

As a RN Utilization Management Care Reviewer, you will use your critical care experience as a RN and skills in collaboration to review the appropriateness of member admission to acute inpatient facilities. You will continue to review members for the duration of the admission to address quality of care, length of stay, and discharge planning. You will be reviewing for the Medicare/Medicaid lines of business.

Your work shift will primarily be Monday-Friday, 8:00 a.m.-5:00 p.m., Arizona business hours Your work will be entirely remote. Arizona residency is a requirement for this position. This role does require availability and focus during the entire shift. If this role sound like the one for you, Apply Today!

Banner Health Network (BHN) 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 BHN, 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.

EOE/Female/Minority/Disability/Veterans (https://www.bannerhealth.com/careers/eeo)

Our organization supports a drug-free work environment.

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EOE/Female/Minority/Disability/Veterans

Banner Health supports a drug-free work environment.

Banner Health complies with applicable federal and state laws and does not discriminate based on race, color, national origin, religion, sex, sexual orientation, gender identity or expression, age, or disability