RN Medical Management Services

Banner Health Corporate; Tucson (AZ); Hybrid; USD 54,000 - 88,000; Full time

Benefits offered by this job

Benefits package

Job summary

Banner Health is seeking an RN for Medical Management Services in a remote role requiring AZ residency. The position emphasizes research-based plan evaluation, prior authorization and care coordination, with hours Mon-Fri 8AM-5PM and Saturday rotations.

The role requires RN licensure in the state, a bachelor’s degree or equivalent experience, and ~5 years of clinical experience, with opportunities to work across CMS, Noridian and other provider lookup tools.

Qualifications

• Requires RN licensure in the state of practice with a Bachelor’s degree or equivalent experience.
• Proficiency in care management, acute/home care environments, and utilization management.
• Strong communication, problem-solving, and time management skills.
• Ability to work effectively in an interdisciplinary team and flexible hours.

Responsibilities

• Manage health plan consumer/beneficiaries across the health care continuum to achieve optimal outcomes.
• Provide pre-service determinations, concurrent review, and case management within Medical Management.
• Collaborate with internal/external stakeholders on prior authorization, utilization management, and case management.
• Document interventions accurately in the medical record and perform follow-up calls for care coordination.
• Educate stakeholders on population health management and evidence-based practices.

Skills

Care management knowledge

Critical thinking

Time management

Interdisciplinary teamwork

Communication skills

Education

RN licensure in state of practice

Bachelor’s degree or equivalent experience

Job description

Department Name: Prior Authorization Work Shift: Day Job Category: Clinical Care

The future is full of possibilities. At Banner Health, we’re excited about what the future holds for health care. That’s why we’re changing the industry to make the experience the best it can be. If you’re ready to change lives, we want to hear from you. Banner Health has been recognized by Becker’s Healthcare as one of the 150 top places to work in health care. In addition, we recently made Newsweek’s list of America’s Greatest Workplaces 2023 for Diversity. These recognitions reflect Banner Health's investment in team members' professional development, wellness benefits, and continued education. It highlights our commitment to advocating for diversity in the workplace, promoting work-life balance, and boosting employee engagement.

In this role of RN Medical Management Services, you are required to be technologically savvy when it comes to research for the plans you will help manage. Sites to aid in that research include CMS, Noridian, Optum360 Encoder Pro, (a provider lookup tool for contracted and noncontracted status,) and more. You will review plans and receive case reviews via fax and a non-clinical team data enters into the system for determinations. The variety of cases received is based on the Prior Authorization Grid for services that must be reviewed for determination. You are required to phone providers, vendors, and members for certain aspects within Banner's processes. An ideal candidate would possess experience in prior authorization.

This is a remote opportunity, with hours of Monday-Friday 8AM-5PM, including Saturday rotations. Must reside in AZ.

Your pay and benefits are important components of your journey at Banner Health. Banner Health offers a variety of benefits to help you and your family. We provide health and financial security options so you can focus on being the best at what you do and enjoying your life Banner Plans & Networks (BPN) is an accountable care organization that joins Arizona's largest health care provider, Banner Health, and an extensive network of primary care and specialty physicians to provide the most comprehensive healthcare solutions for Maricopa County and parts of Pinal County. Through BPN, known nationally as an innovative leader in new health care models, insurance plans and physicians are coming together to work collaboratively to keep members in optimal health, while reducing costs.

POSITION SUMMARY

This position provides support and execution of programs and tactics used to influence provider and health plan consumer/beneficiaries’ behaviors in order to achieve right care in the right place at the right time and the appropriate cost. Plans and provides support for health plan consumers/beneficiaries to align with the objectives of triple aim. This position is responsible to process health plan medical pre-service requests, provide case management, care coordination and perform utilization management duties within the appropriate time period as outlined in the Medical Management Program Descriptions, and in accordance with all federal and state regulations.

CORE FUNCTIONS

• 1. Manages health Plan consumer/beneficiaries’ across the health care continuum to achieve optimal clinical, financial, operational, and satisfaction outcomes.
• 2. Provides pre-service determinations, concurrent review, and case management functions within Medical Management. Ensures quality of service and consistent documentation.
• 3. Works collaboratively with both internal and external customers in assisting health Plan consumer/beneficiaries’ and providers with issues related to prior authorization, utilization management, and/or case management. Meets internal and external customer service expectations regarding duties and professionalism.
• 4. Performs transfer of accurate, pertinent patient information to support the pre-service determination(s), the transition of patient care needs through the continuum of care, and performs follow-up calls for advanced care coordination. Documents accurately and timely, all interventions and necessary patient related activities in the correct medical record.
• 5. Evaluates the medical necessity and appropriateness of care, optimizing health Plan consumer/beneficiaries’ outcomes. Identifies issues that may delay patient services and refers to case management, when indicated to facilitate resolution of these issues, pre-service, concurrently and post-service.
• 6. Provides ongoing education to internal and external stakeholders that play a critical role in the continuum of care model. Training topics consist of population health management, evidence based practices, and all other topics that impact medical management functions.
• 7. Identifies and refers requests for services to the appropriate Medical Director and/or other physician clinical peer when guidelines are not clearly met. Conducts call rotation for the health plan, as well as departmental call rotation for holiday.
• 8. Maintains a thorough understanding of each plan, including the Evidence of Coverage, Summary Plan Description authorization requirements, and all applicable federal, state and commercial criteria, such as CMS, MCG, and Hayes.
• 9. Has freedom to determine how to best accomplish functions within established procedures. Confers with supervisor on any unusual situations. Positions are entity based with no budgetary responsibility.

MINIMUM QUALIFICATIONS

• Requires Registered Nurse (R.N.) licensure in the state of practice. All license or certification must identify the issuing state or entity, type of licensure and expiration date or evidence that the certification is the type that does not expire. A bachelor’s degree or equivalent experience.
• Requires proficiency level typically achieved with five years of clinical experience.
• Must have a working knowledge of care management, acute care and/or home care environments, community resources and resource/utilization management.
• Must demonstrate critical thinking skills, problem-solving abilities, effective communication skills, 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 QUALIFICATIONS

• Certification(s) related to field, such as Certified Case Manager (CCM), MCG Certification(s), RN-BC Registered Nurse Case Manager, Certification in Managed Care Nursing (CMCN). Additional related education and/or experience preferred.

Estimated Pay Range: $38.67 - $64.45 / hour

Banner Health offers a variety of benefits to help you and your family. We are proud to offer a comprehensive benefit package for all benefit-eligible positions.

EEO/Disabled/Veterans Banner Health supports a drug-free work environment. Privacy Policy: Banner Health is one of the largest, nonprofit health care systems in the country and the leading nonprofit provider of hospital services in all the communities we serve. Throughout our network of hospitals, primary care health centers, research centers, labs, physician practices and more, our skilled and compassionate professionals use the latest technology to make health care easier, so life can be better. The many locations, career opportunities, and benefits offered at Banner Health help to make the Banner Journey unique and fulfilling for every employee. We are proud to offer a comprehensive benefit package for all benefit-eligible positions. Please visit our Benefits Guide for more information.