Registered Nurse - Utilization Review Per Diem

HonorHealth; Arizona; Remote; USD 80,000 - 100,000; Full time

Job summary

HonorHealth is seeking an RN Utilization Review Specialist to review and monitor health care service utilization, ensuring appropriate levels of care and medical necessity across admissions and payer types. You will coordinate medical necessity reviews for Medicare, AHCCCS, self-pay, and other payers from admission through discharge.

You will work with the Care Management team to ensure documentation supports services, collaborate with physicians, payers, and care teams to address denials and

Qualifications

• Associate degree in nursing is required or
• Bachelor's degree in nursing preferred
• 1 year UR/UM or Case Management experience required
• 3 years RN in an acute care setting required

Responsibilities

• Reviews clinical documentation and ensures level of care reflects services rendered and severity of illness.
• Performs initial and concurrent reviews for admission and ongoing care.
• Collaborates with physicians, case managers, payers and others to appeal denials and address contract guidelines.
• Interacts with Care Management to provide quality outcome data and supports data reporting.
• Initiates chart reviews and rounds to ensure continuity of utilization reviews.

Skills

Utilization Review

RN experience

Collaboration

Education

Associates in Nursing

Bachelors in Nursing

Job description

• Seeking Applicants That Can Work at Least 8 Shifts per Month

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

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