Remote RN: Medical Management & Prior Authorization

Banner Health Corporate; Vail (AZ); Hybrid; USD 101,521,000 - 169,202,000; Full time

Job summary

Banner Health Corporate is seeking an experienced RN for Medical Management Services to support health plan pre-service determinations and case management. This is a remote opportunity with Monday–Friday 8AM–5PM hours and Saturday rotations; AZ residents only.

The role requires strong care management knowledge, five years of clinical experience, and RN licensure. You will coordinate with providers, members, and vendors, and ensure compliant utilization management across plans.

Qualifications

• Requires RN licensure in the state of practice. Licensure must identify issuing state, type, and expiration date or indicate non-expiring certification.
• A bachelor’s degree or equivalent experience is required.
• Requires proficiency level typically achieved with five years of clinical experience.
• Working knowledge of care management, acute care and/or home care environments, community resources and utilization management.
• Must demonstrate critical thinking, problem-solving, effective communication, and time management skills.
• Must demonstrate ability to work effectively in an interdisciplinary team format.
• Must be able to work flexible hours and take rotating call after hours.
• Preferred certifications include CCM, MCG Certification(s), RN-BC, CMCN.

Responsibilities

• Manages health plan consumer/beneficiaries across the health care continuum to achieve optimal outcomes.
• Provides pre-service determinations and concurrent review within Medical Management; ensures quality and documentation.
• Collaborates with internal and external customers on prior authorization, utilization management, and case management; meets service expectations.
• Transfers accurate patient information to support determinations and facilitates care transitions; documents interventions timely.
• Evaluates medical necessity and appropriateness of care; refers issues to case management when needed.
• Provides ongoing education on population health management and evidence-based practices to stakeholders.
• Identifies and refers requests to Medical Director when guidelines aren’t clearly met; participates in call rotations.
• Maintains knowledge of plans, criteria, and regulatory requirements (CMS, MCG, Hayes).

Skills

RN licensure

Clinical experience 5+ years

Care management knowledge

Critical thinking

Communication skills

Time management

Interdisciplinary teamwork

Flexibility & rotating call

Education

Bachelor's degree or equivalent experience

Job description

Banner Health Corporate is seeking an experienced RN for Medical Management Services to support health plan pre-service determinations and case management. This is a remote opportunity with Monday–Friday 8AM–5PM hours and Saturday rotations; AZ residents only.

The role requires strong care management knowledge, five years of clinical experience, and RN licensure. You will coordinate with providers, members, and vendors, and ensure compliant utilization management across plans.