Registered Nurse (RN) - Utilization Review
Job summary
Work model
YOU MUST reside in Arizona for this role*
It is remote but you must reside in AZ.
Responsibilities
Working knowledge of Milliman or InterQual criteria a must.
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.
Key Functions
This position integrates national standards for case management scope of services including:
Utilization Management
- Supporting medical necessity and denial prevention
Payer Coordination
- Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient
Compliance
- Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
Education
- Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits
Supervision
- May oversee work delegated to Central Utilization Review LVN/LPN Case Manager and/or Central Utilization Authorization Coordinator