Good health care is key to a good life. At Banner Health, we understand that, and that's why we work hard every day to make a difference in people's lives. Do you like the idea of making a positive change in people's lives - and your own? If so, this could be the perfect opportunity for you.
This is a Virtual/work from home position that is both autonomous and team-centered.
Your pay and benefits are important components of your journey at Banner Health. Banner Health offers a variety of benefits to help you and your family. We provide health and financial security options so you can focus on being the best at what you do and enjoying your life.
Banner Health Network (BHN) 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 BHN, 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.
Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Banner Health with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.
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. Basic Life Support certification or ability to obtain within three months of hire.
Five years of clinical nursing experience. Utilization Management 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.
What might draw you to Banner Health? A great health care career, of course—and a great place to live, no matter what stage of life you’re in. With facilities across the West, there is a health care career for everyone, from big city living in the Phoenix area to friendly small towns in the mountains and plains. As one of the largest nonprofit health systems in the country, Banner Health offers both the stability that comes with success and the possibility of exploring new areas of the country. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages:
Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health.
Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible.
The size, success and growth of our system provide you with the stability and options to pursue your desired career path.
Competitive compensation and comprehensive benefits offer you options to complement your unique needs.