Registered Nurse Utilization Review Full Time Days BHS

POSITION SUMMARY

The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case-by-case basis. This position integrates national standards for case management scope of services including:

• Utilization Management services supporting medical necessity and denial prevention
• Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient
• Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
• Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits
• Other related duties as assigned

POSITION QUALIFICATIONS
MINIMUM EDUCATION: Graduate of an accredited School of Nursing
PREFERRED EDUCATION: Bachelors or Masters Degree in Nursing
MINIMUM EXPERIENCE: 2 years acute hospital or behavioral health patient care experience with at least 1 year utilization review in an acute hospital or commercial/managed care payer setting.
PREFERRED EXPERIENCE: Previous Case Management Supervisory experience.
REQUIRED CERTIFICATIONS/LICENSURE: Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN license for state(s) covered.
PREFERRED CERTIFICATIONS/LICENSURE: Accredited Case Management (ACM)
REQUIRED COURSES/ COMPLETIONS: Must complete Tenet’s InterQual® education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better. Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire. Orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQual®, Utilization Management, and other topics specific to case management.

#LI-NS1

Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law. 

Responsible for providing accurate medical necessity screening and submission for Physician Advisor review. Securing and documenting authorization for services from payers. Managing concurrent disputes. Collaborating with payers, physicians, office staff, and ancillary departments. Timely, complete, and concise documentation in the Tenet Case Management documentation system. Maintenance of accurate patient demographic and insurance information. Identification and documentation of potentially avoidable days. Identification and reporting over and underutilization.

Education:

Required: Graduate of an accredited school of nursing
Preferred: Academic degree in nursing (bachelor's or master's)

Experience:

Required: 2 years of acute hospital or behavioral health patient care experience with at least 1 year utilization review in an acute hospital or commercial/managed care payer setting

Certifications:

Required: RN. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN license for state(s) covered.
Preferred: Accredited Case Manager (ACM)

Physical Demands:

Lift/position up to 25 lbs. Push/pull up to 25 lbs.of force. Frequent sitting. Moderate standing, walking, reaching, stooping, and bending. Manual dexterity, mobility, touch, auditory to perform all the related duties of the position.

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We are a community built on care. Our caregivers and supporting staff extend compassion to those in need, helping to improve the health and well-being of those we serve, and provide comfort and healing. Your community is our community.
Our Story
We started out as a small operation in California. In May 1969, we acquir