Registered Nurse - Utilization Review Per Diem

10 John C. Lincoln Medical Center; Arizona; Hybrid; USD 80,000 - 110,000; Full time

Job summary

HonorHealth is seeking a Utilization Review RN Specialist to review and monitor health care utilization, ensuring medical necessity across inpatient and outpatient settings. You will coordinate reviews for Medicare, AHCCCS, and other payers, working with the Care Management team to optimize resource use and outcomes.

The role requires RN licensure, 1 year UR/UM or case management experience, and 3 years as an RN in acute care. Associates or Bachelors in Nursing are preferred.

Qualifications

• UR/UM review and case management concept
• Collaboration with care teams, physicians and payers
• Attention to medical necessity and documentation accuracy

Responsibilities

• Review and monitor utilization of health care services for Medicare, AHCCCS, self-pay and other payers.
• Coordinate medical necessity review upon admission and concurrently throughout stay.
• Partner with Care Management to improve outcomes and data reporting.
• Initiate chart reviews, conduct follow-ups, and round on patients for UR reviews.
• Notify physicians of documentation issues and determine hospital level of care.
• Support system to develop complete documentation for data reporting purposes.

Job description

Primary City/State:

Virtual Arizona Category:

Case Management Shift:

Day Department:

Case Management

Seeking Applicants That Can Work at Least 8 Shifts per Month

Great care starts with great people. (Like you.)

At HonorHealth, you'll find something special. From humble beginnings in 1927 to one of Arizona's largest nonprofit healthcare systems, our culture is built on warmth and neighborly kindness. Behind every smile is a highly skilled professional with deep expertise and an unwavering dedication to what matters most - caring for the health and well-being of people and communities across the greater Phoenix area.

Responsibilities:

JOB SUMMARY

The Utilization Review RN Specialist reviews and monitors utilization of health care services with the goal of maintaining high quality cost-effective care. Ensures appropriate level of care through comprehensive review for medical necessity of extended stay, outpatient observation, and inpatient stays and the utilization of ancillary services. Responsible for coordinating and conducting medical necessity reviews for all Medicare, AHCCCS, Self-pay, and all other payers, upon admission and concurrently throughout the admission.

ESSENTIAL FUNCTIONS

Reviews clinical documentation and facilitates modifications (as needed) to ensure that documentation accurately reflects the level of service rendered and severity of illness (in compliance with government and other regulations) for all patients. Performs initial and concurrent reviews on all patients entering the health care continuum.

Facilitates the delivery of services to patients and families through effective utilization of available resources. Performs medical record reviews, as required by payer. Interfaces with Care Management team to provide information regarding quality outcome measurements (such as timeliness and appropriateness of services). Collaborates with physicians, case managers, payers and others to appeal individual denials and trended issues related to contract guidelines. Works with medical records, finance and physician groups to develop systems to facilitate complete documentation for data reporting purposes.

Initiates chart reviews, conducts follow-up reviews, and rounds on patients to ensure continuity of UR reviews.

Maintains a system to identify admissions with specific diagnosis / DRG classifications or other categories of admissions. Notifies attending physicians and house staff or other appropriate staff of documentation issues requiring clarification.

Determines qualifications for hospital level of care based on set criteria.

Performs other duties as assigned.

EDUCATION

Associates in Nursing from an accredited NLN/CCNE institution Required or Bachelors in Nursing from an accredited NLN/CCNE institution Preferred

EXPERIENCE

1 year experience in UR/UM or Case Management Required

3 years Registered Nurse in an acute care setting. Required

LICENSES AND CERTIFICATIONS

Registered Nurse (RN) - License State And/Or Compact State Licensure Required

Certified Case Manager - Certification Certified Case Management (ACM) Case Management Certification Preferred

We're all in for your career.