Registered Nurse (RN) - Utilization Review
About The Position
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; May oversee work delegated to Central Utilization Review LVN/LPN Case Manager and/or Central Utilization Authorization Coordinator. Join our dedicated healthcare team where compassion meets innovation! As a Registered Nurse with us, you'll have the opportunity to make a meaningful impact in patients' lives while enjoying a supportive work environment that fosters professional growth and work-life balance. Ready to be a vital part of our mission? Apply today and bring your passion for nursing to a place where it truly matters!
Requirements
- Registered Nurse (RN) license
- Experience in utilization review or case management
- Knowledge of medical necessity criteria
- Familiarity with payer negotiations
- Understanding of state and federal regulatory requirements
- Knowledge of TJC accreditation standards
- Ability to educate various stakeholders
Nice To Haves
- Experience overseeing LVN/LPN Case Managers or Utilization Authorization Coordinators
Responsibilities
- 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.
- Ensure that care is provided at the appropriate level of care based on medical necessity.
- Manage the medical necessity process for accurate and timely payment for services, which may require negotiation with a payer on a case by case basis.
- Integrate national standards for case management scope of services including: Utilization Management services supporting medical necessity and denial prevention.
- Coordinate with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient.
- Ensure compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy.
- Provide education to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits.
- May oversee work delegated to Central Utilization Review LVN/LPN Case Manager and/or Central Utilization Authorization Coordinator.
Benefits
- Medical, dental, vision, and life insurance
- 401(k) retirement savings plan with employer match
- Generous paid time off
- Career development and continuing education opportunities
- Health savings accounts
- Healthcare & dependent flexible spending accounts
- Employee Assistance program
- Employee discount program
- Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
5,001-10,000 employees
