The Utilization Review RN Specialist monitors healthcare services to ensure medical necessity and cost-effective care for inpatient and outpatient stays. They collaborate with physicians and care teams to facilitate documentation, manage appeals, and ensure compliance with regulatory standards.
Primary City/State:
Virtual - Arizona
Category:
Case Management
Shift:
Day
Department:
Case Management
7:30 -4:00
Team Operates Monday through Sunday
Remote After Training
Great care starts with great people. (Like you.)
At HonorHealth, you’ll find something special. From humble beginnings in 1927 to one of Arizona’s largest nonprofit healthcare systems, our culture is built on warmth and neighborly kindness. Behind every smile is a highly skilled professional with deep expertise and an unwavering dedication to what matters most — caring for the health and well-being of people and communities across the greater Phoenix area.
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. Essential Functions
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 rounds on patients to ensure continuity of UR reviews.
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.
Education
Bachelor's Degree in Nursing from an accredited NLN/CCNE institution - Preferred
Associate's Degree in Nursing from an accredited NLN/CCNE institution - Required
Experience
1 year experience in UR/UM or Case Management - Required
3 years Registered Nurse in an acute care setting. - Required
Licenses and Certifications
Registered Nurse (RN) State And/Or Compact State Licensure - Required
Certified Case Management (ACM) Case Management Certification - Preferred
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