This is a remote position( must live in AZ) .
Welcome to Abrazo Health Network, where making a real difference in people’s lives is at the heart of everything we do. Beyond just medical treatments, we believe in the power of genuine relationships and heartfelt compassion. It’s what sets us apart and makes us truly special.
When you join our team, you’re not just stepping into a job – you’re becoming part of a community that uplifts and supports each other every day. We know that healthcare requires a unique blend of talent and dedication, and we are fully committed to providing an environment that enriches and rewards your journey.
Picture yourself among the brightest healthcare professionals, all united by a common purpose: caring for our community with unwavering commitment. At Abrazo Health, you won’t just find colleagues; you’ll find awe-inspiring teammates who share your passion for making a meaningful impact.
If you’re ready to go above and beyond, to embrace the energy and camaraderie that Abrazo Health offers, then join us on this incredible adventure. Together, we’ll embrace a healthier world – one patient at a time. Let your career find its purpose here at Abrazo.
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
Job Responsibilities:
- Accurate medical necessity screening and submission for Physician Advisor review
- Securing and documenting authorization for services from payers
- Managing concurrent disputes
- Collaborating with payers, physicians, office staff and ancillary departments
- Timely, complete and concise documentation in the Tenet Case Management documentation system
- Maintenance of accurate patient demographic and insurance information
- Identification and documentation of potentially avoidable days
- Identification and reporting over and underutilization
THE RN UTILIZATION REVIEW FULL TIME DAYS CANDIDATE WILL POSSESS THE FOLLOWING EDUCATION, LICENSE/CERTIFICATIONS, AND EXPERIENCE.
EDUCATION
Required: Graduate of an accredited school of nursing.
Preferred: Academic degree in nursing (bachelor’s or master’s)
LICENSE/CERTIFICATIONS
Required: RN. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN license for state(s) covered.
Preferred: Accredited Case Manager (ACM).
EXPERIENCE
Required: Must a full working knowledge of InterQual or Milliman criteria. 1 year utilization review in an acute hospital or commercial/managed care payer setting.
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Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.