RN UTILIZATION REVIEW SPECIALIST - Remote
- Full-Time
- Scottsdale, AZ
- HonorHealth
- Posted 1 year ago – Accepting applications
Job Description
Overview
HonorHealth offers a diverse benefits portfolio for our full-time and part-time team members designed to help you and your family live your best lives. Visit honorhealth.com/benefits to learn more.
Join us. Let’s go beyond expectations and transform healthcare together.
HonorHealth is a non-profit, local community healthcare system serving an area of 1.6 million people in the greater Phoenix area. The network encompasses six acute-care hospitals, an extensive medical group, outpatient surgery centers, a cancer care network, clinical research, medical education, a foundation, and community services with approximately 13,100 team members, 3,500 affiliated providers and nearly 700 volunteers. HonorHealth was formed by a merger between Scottsdale Healthcare and John C. Lincoln Health Network. HonorHealth’s mission is to improve the health and well-being of those we serve.
As a community healthcare system, we have a unique responsibility to keep our facilities as safe as possible to protect our patients and team members. With this in mind, we require all new hires to have received the first dose of a COVID-19 vaccine before their start date and be scheduled for their second dose. New hires who choose to receive the Johnson & Johnson vaccine only need one dose to fulfill this requirement. Reasonable accommodations will be considered. Please note – this organization is a tobacco free campus. In order to be an eligible candidate you will need to test negative on a tobacco (cotinine) test during prescreening. If you test positive you will be unable to reapply for 30 days. If you test positive a second time you will ineligible to reapply for 1 year.
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.
Reviews 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 escalates secondary reviews to Physician Advisor as necessary.
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.
Determines qualifications for hospital level of care based on set criteria.
Performs other duties as assigned.
Qualifications
Education
Associate's Degree in Nursing from an accredited NLN/CCNE institution Required
Experience
3 years as a Registered Nurse in an acute care setting Required
1 year experience in UR/UM or Case Management Required
Licenses and Certifications
Registered Nurse (RN) State And/Or Compact State Licensure Required
Apply to this Job
- This position is eligible for $10,000.00 Bonus Potential
HonorHealth offers a diverse benefits portfolio for our full-time and part-time team members designed to help you and your family live your best lives. Visit honorhealth.com/benefits to learn more.
Join us. Let’s go beyond expectations and transform healthcare together.
HonorHealth is a non-profit, local community healthcare system serving an area of 1.6 million people in the greater Phoenix area. The network encompasses six acute-care hospitals, an extensive medical group, outpatient surgery centers, a cancer care network, clinical research, medical education, a foundation, and community services with approximately 13,100 team members, 3,500 affiliated providers and nearly 700 volunteers. HonorHealth was formed by a merger between Scottsdale Healthcare and John C. Lincoln Health Network. HonorHealth’s mission is to improve the health and well-being of those we serve.
As a community healthcare system, we have a unique responsibility to keep our facilities as safe as possible to protect our patients and team members. With this in mind, we require all new hires to have received the first dose of a COVID-19 vaccine before their start date and be scheduled for their second dose. New hires who choose to receive the Johnson & Johnson vaccine only need one dose to fulfill this requirement. Reasonable accommodations will be considered. Please note – this organization is a tobacco free campus. In order to be an eligible candidate you will need to test negative on a tobacco (cotinine) test during prescreening. If you test positive you will be unable to reapply for 30 days. If you test positive a second time you will ineligible to reapply for 1 year.
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.
Reviews 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 escalates secondary reviews to Physician Advisor as necessary.
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.
Determines qualifications for hospital level of care based on set criteria.
Performs other duties as assigned.
Qualifications
Education
Associate's Degree in Nursing from an accredited NLN/CCNE institution Required
Experience
3 years as a Registered Nurse in an acute care setting Required
1 year experience in UR/UM or Case Management Required
Licenses and Certifications
Registered Nurse (RN) State And/Or Compact State Licensure Required