Registered Nurse Utilization Review Per Diem Days

Description

Summary:

The individual in this position is responsible to facilitate effective resource coordination to help patients
achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for
ensuring that care is provided at the appropriate level of care based on medical necessity. This position
manages medical necessity process for accurate and timely payment for services which may require
negotiation with a payer on a case by case basis. This position integrates national standards for case
management scope of services including:

- Utilization Management services supporting medical necessity and denial prevention
- Coordination with payers to authorize appropriate level of care and length of stay for medically
necessary services required for the patient
- Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet
policy
- Education provided to payers, physicians, hospital/office staff and ancillary departments related to
covered services and administration of benefits

The individual’s responsibilities include the following activities: a) accurate medical necessity screening
and submission for Physician Advisor review, b) securing and documenting authorization for services from
payers, c) managing concurrent disputes, d) collaborating with payers, physicians, office staff and ancillary
departments, e) timely, complete and concise documentation in the Tenet Case Management documentation
system, f) maintenance of accurate patient demographic and insurance information, g) identification and
documentation of potentially avoidable days, h) identification and reporting over and underutilization, i)
and other duties as assigned.

Qualifications