Registered Nurse - Utilization Review Per Diem

HonorHealth; Phoenix (AZ); Remote; USD 75,000 - 95,000; Full time

Job summary

HonorHealth is seeking an Utilization Review RN Specialist to review and monitor the utilization of health care services, ensuring medical necessity and appropriate levels of care. You will coordinate reviews for Medicare, AHCCCS, self-pay, and others from admission onward.

You will work with the Care Management team to address documentation issues, support data reporting, and collaborate with physicians, payers, and staff to optimize care and outcomes.

Qualifications

• RN licensure in state or compact state
• ACM Case Management Certification (CCM) preferred
• 1 year UR/UM or Case Management experience preferred
• 3 years RN in acute care setting required

Responsibilities

• Reviews medical necessity and utilization for Medicare, AHCCCS, self-pay and other payers.
• Coordinates and conducts medical necessity reviews at admission and concurrently.
• Interfaces with care management, physicians, payers and others to address denials and documentation gaps.
• Initiates chart reviews and follows up to ensure accurate reflection of care.
• Supports data reporting and quality outcome measurements in UR reviews.

Skills

Case Management

Care Coordination

Interdisciplinary Collaboration

Education

Associate's in Nursing

Bachelor's in Nursing

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 FUNCTIONSReviews 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.Determining qualifications for hospital level of care based on set criteria.Performs other duties as assigned.EDUCATIONAssociates in Nursing from an accredited NLN/CCNE institution

Required

orBachelors in Nursing from an accredited NLN/CCNE institution

PreferredEXPERIENCE1 year experience in UR/UM or Case Management

Required3 years Registered Nurse in an acute care setting.

RequiredLICENSES AND CERTIFICATIONSRegistered Nurse (RN) - License State And/Or Compact State Licensure

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

Preferred

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