Registered Nurse (RN) - Utilization Review

Overview Join our dedicated healthcare team where compassion meets innovation! As a Registered Nurse with us, you\'ll have the opportunity to make a meaningful impact in patients\' lives while enjoying a supportive work environment that fosters professional growth and work-life balance. Ready to be a vital part of our mission? Apply today and bring your passion for nursing to a place where it truly matters! At Tenet Healthcare, We Understand That Our Greatest Asset Is Our Dedicated Team Of Professionals. That\u2019s Why We Offer More Than a Job – We Provide a Comprehensive Benefit Package That Prioritizes Your Health, Professional Development, And Work-life Balance. The Available Plans And Programs Include: Medical, dental, vision, and life insurance 401(k) retirement savings plan with employer match Generous paid time off Career development and continuing education opportunities Health savings accounts, healthcare & dependent flexible spending accounts Employee Assistance program, Employee discount program Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance Note : Eligibility for benefits may vary by location and is determined by employment status Job Summary Job Shift: Days Job Type: Full Time 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; and Education provided to payers, physicians, hospital/office staff, and ancillary departments related to covered services and administration of benefits. Responsibilities 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. Qualifications 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) Organization Description The Hospitals of Providence have faithfully been serving our community since 1902. Generations of families have chosen our hospitals to be a steward of health in the El Paso community. Our five hospitals include a childrens hospital committed to providing the care patients need, when they need it. Today, the Hospitals of Providence are comprised of our region\u2019s most trusted hospitals, each dedicated to meeting our families specific healthcare needs. Join our team! Employment practices will not be influenced or affected by an applicant\u2019s or employee\u2019s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship. Tenet participates in the E-Verify program. Follow the link below for additional information. E-Verify: The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations. View phone number on click.appcast.io Employment practices will not be influenced or affected by an applicant\u2019s or employee\u2019s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship. 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) 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. #J-18808-Ljbffr The Hospitals of Providence