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POSITION SUMMARY
This position, within the Utilization Management Department, will determine the medical appropriateness of requested services by reviewing clinical information and applying evidenced-based guidelines. This position will interact with providers, members, internal and external service teams to obtain necessary information and communicate determinations. In addition to pre-service, admission, and concurrent review determinations, this position will be responsible for managing length of stay, discharge planning, resources, and identification of potential quality of care or safety concerns.

CORE FUNCTIONS
1. Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness, and compliance with all state and federal regulations and guidelines.

2. Analyzes clinical services from members or providers against evidence-based guidelines.

3. Identifies appropriate benefits, eligibility, and expected length of stay for requested services, treatments, and/or procedures.

4. Conducts inpatient reviews to determine financial responsibility. May also perform authorization reviews and/or related duties as needed. Processes requests within required timelines.

5. Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner. Makes appropriate referrals to other clinical programs.

6. Collaborates with multidisciplinary teams to promote Banner Health's Integrated model.

7. Adheres to UM policies and procedures.

MINIMUM QUALIFICATIONS

Bachelor’s degree in nursing or equivalent working knowledge.

Active, unrestricted State Registered Nursing (RN) license in good standing. MCG certification or ability to obtain within six months of hire.

Five years of clinical nursing experience or equivalent working knowledge.

Must be highly proficient with computer usage, typing, Microsoft Suite, and possess the ability to navigate through multiple platforms. Must be highly proficient in medical record review including EMR and paper/fax platforms.

PREFERRED QUALIFICATIONS

Two to three years of Utilization Management experience using MCG, CMS, and clinical criteria. MSN preferred. Case Management Certification (CCM or RN-BC or CMCN). Utilization Management Certification. Certified Professional in Healthcare Quality Certification (CPHQ). Experience with Medicare Advantage, ACOs, Commercial, Dual Eligible, AHCCCS, and/or ALTCS. Experience with URAC and NCQA accreditation process. Experience using Medical Management software platforms.

Additional related education and/or experience preferred.

DATE APPROVED 08/21/2022

EOE/Female/Minority/Disability/Veterans

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