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; Other related duties as assigned.
Requirements
- Graduate of an accredited School of Nursing
- 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.
- 2 years acute hospital or behavioral health patient care experience with at least 1 year utilization review in an acute hospital or commercial/managed care payer setting.
- Must complete Tenet’s InterQual® education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better.
- Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire.
- Orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQual®, Utilization Management, and other topics specific to case management.
Nice To Haves
- Bachelors or Masters Degree in Nursing
- Previous Case Management Supervisory experience.
- Accredited Case Management (ACM)
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.
- Provide 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.
- Perform other related duties as assigned.
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
Education Level
Associate degree
