Registered Nurse (RN) - Utilization Review
Abrazo Community Health Network
Phoenix, AZ
5x8 hrs, Days

**MUST reside in AZ to be considered for this role**

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 benefitsJob 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.

Remote position- only local AZ candidates are being considered.