[Hiring] RN Utilization Management Care Reviewer @Banner Health

Role Description

Nursing careers are better at Banner Health. We’ve built smarter processes to help nurses focus on what really matters. If you want to make a difference in people’s lives - this could be the opportunity you’ve been waiting for.

As a Remote 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 safe, 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
• Help improve member outcomes

This is a remote, salaried opportunity. CANDIDATES MUST RESIDE IN THE STATE OF ARIZONA. The schedule is as follows: Monday-Friday 8am-5pm, no weekends, and major holidays off.

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
• 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
• Identification of potential quality of care or safety concerns

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
• Highly proficient with computer usage, typing, Microsoft Suite
• Ability to navigate through multiple platforms
• Highly proficient in medical record review including EMR and paper/fax platforms

Requirements

• Two to three years of Utilization Management experience using MCG, CMS, and clinical criteria (preferred)
• 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

Benefits

• Estimated Pay Range: $37.14 - $61.90 / hour
• Banner Health is committed to pay equity and transparency
• Actual pay determined at offer will be based on years of relevant work experience, education, certifications, skills, and geographic location
• Review of current employees in similar roles to ensure pay equity is achieved and maintained

Company Description

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.