Registered Nurse (RN) - Utilization Review

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

· May oversee work delegated to Central Utilization Review LVN/LPN Case Manager and/or Central Utilization Authorization Coordinator

• 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 and other duties as assigned.

• Minimum Requirements
  • Experience: Minimum two years acute care experience in UR or other related utilization review experience.
  • Education: Graduate of an accredited school of nursing.  
  • Certifications: active Registered Nurse license
• Preferred Requirements
  • Education: BSN
• Certifications:  Accredited Case Manager (ACM) preferred.

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