RN Utilization Review FT Days

RN Utilization Review Full Time Days Position 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.

THE RN UTILIZATION REVIEW CANDIDATE WILL POSSESS THE FOLLOWING EDUCATION, LICENSE/CERTIFICATIONS, AND EXPERIENCE.
Education Preferred: BSN Required qualifications include an active Registered Nurse license with at least two years acute hospital or Behavioral Health patient care experience. BSN preferred (unless required * if Magnet Hospital). Accredited Case Manager (ACM) preferred. Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to work in a fast paced environment, critical thinking and problem solving skills and computer literacy. Required: Active and valid RN license. Preferred: Accredited Case Manager (ACM).