RN Utilization Management Care Reviewer

Department Name: Utilization Mgmt

Work Shift:

Day

Job Category:

Clinical Care

Nursing careers are better at Banner Health. We’ve built smarter processes to help nurses focus on what really matters. If you want to make a difference in people’s lives - this could be the opportunity you’ve been waiting for.

As a Remote RN Utilization Management Care Reviewer , you’ll play a critical role in ensuring our Medicare Advantage and AHCCCS members receive the right care at the right time while supporting safe, successful transitions after hospitalization. Collaborating with post-acute facilities and interdisciplinary care teams, you’ll apply your clinical expertise to review medical necessity, optimize length of stay, and help improve member outcomes. If you have a passion for utilization management, care coordination, or case management—and experience with MCG or InterQual is a plus—we’d love to hear from you!

This is a remote, salaried opportunity. CANDIDATES MUST RESIDE IN THE STATE OF ARIZONA. The schedule is as follows: Monday-Friday 8am-5pm, no weekends, and major holidays off ,

Banner Plans & Networks (BPN) is an accountable care organization that joins Arizona's largest health care provider, Banner Health, and an extensive network of primary care and specialty physicians to provide the most comprehensive healthcare solutions for Maricopa County and parts of Pinal County. Through BPN, known nationally as an innovative leader in new health care models, insurance plans and physicians are coming together to work collaboratively to keep members in optimal health, while reducing costs.

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.

Estimated Pay Range:

$37.14 - $61.90 / hour Banner Health is committed to pay equity and transparency. The posted compensation range is a reasonable estimate that extends from the lowest to the highest pay Banner Health in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. This range is based on possible base salaries and does not include the value of our total rewards package. Actual pay determined at offer will be based on years of relevant work experience, education, certifications, skills, and geographic location, along with a review of current employees in similar roles to ensure pay equity is achieved and maintained.

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