RN Medical Management Services

Banner Health•Tucson, AZ

1d•$39 - $64•Remote

About The Position

This position supports and executes programs and tactics that influence provider and health plan consumer/beneficiary behaviors to promote the right care, in the right place, at the right time, and at appropriate cost. The role supports health plan consumers and beneficiaries in alignment with triple-aim objectives and processes medical pre-service requests, provides case management and care coordination, and performs utilization management within required timeframes and applicable federal and state regulations. The RN reviews health plan cases and medical service requests for determination, evaluates medical necessity and appropriateness of care, and supports transitions and coordination across the care continuum. Work includes research using resources such as CMS, Noridian, Optum360 Encoder Pro, and other provider lookup tools; cases may be received by fax and entered into the system by non-clinical staff. The role also contacts providers, vendors, and members as needed. This is a remote position for candidates residing in Arizona, with a Monday–Friday schedule of 8:00 a.m.–5:00 p.m. and Saturday rotations. Flexible hours and rotating after-hours and holiday call duties are required.

Requirements

Registered Nurse (R.N.) licensure in the state of practice.
Bachelor’s degree or equivalent experience.
Five years of clinical experience, or proficiency typically achieved with five years of clinical experience.
Working knowledge of care management, acute care and/or home care environments, community resources, and resource/utilization management.
Critical thinking, problem-solving, effective communication, and time management skills.
Ability to work effectively in an interdisciplinary team format.
Ability to work flexible hours and take rotating after-hours call.
Must reside in Arizona.

Nice To Haves

Certification related to the field, such as Certified Case Manager (CCM), MCG certification, RN-BC Registered Nurse Case Manager, or Certification in Managed Care Nursing (CMCN).
Additional related education and/or experience.
Experience in prior authorization.

Responsibilities

Manage health plan consumers and beneficiaries across the health care continuum to support clinical, financial, operational, and satisfaction outcomes.
Provide pre-service determinations, concurrent review, and case management functions within Medical Management, maintaining service quality and consistent documentation.
Collaborate with internal and external customers to assist consumers, beneficiaries, and providers with prior authorization, utilization management, and case management issues.
Transfer accurate, pertinent patient information to support pre-service determinations and transitions of care; conduct follow-up calls for advanced care coordination and document interventions and patient-related activities accurately and promptly.
Evaluate medical necessity and appropriateness of care, identify issues that may delay services, and refer matters to case management when indicated.
Provide ongoing education to internal and external stakeholders on population health management, evidence-based practices, and other topics affecting medical management.
Refer service requests to the appropriate Medical Director or other physician clinical peer when guidelines are not clearly met.
Participate in health plan call rotations and departmental holiday call rotations.
Maintain understanding of each plan, including Evidence of Coverage, Summary Plan Description authorization requirements, and applicable federal, state, and commercial criteria such as CMS, MCG, and Hayes.
Research plans using resources including CMS, Noridian, Optum360 Encoder Pro, and provider lookup tools.
Contact providers, vendors, and members as required by Banner processes.