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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 provides support and execution of programs and tactics used to influence provider and health plan consumer/beneficiaries' behaviors in order to achieve right care in the right place at the right time and the appropriate cost. Plans and provides support for health plan consumers/beneficiaries to align with the objectives of triple aim. This position is responsible to process health plan medical pre-service requests, provide case management, care coordination and perform utilization management duties within the appropriate time period as outlined in the Medical Management Program Descriptions, and in accordance with all federal and state regulations.
CORE FUNCTIONS 1. Manages health Plan consumer/beneficiaries' across the health care continuum to achieve optimal clinical, financial, operational, and satisfaction outcomes.
2. Provides pre-service determinations, concurrent review, and case management functions within Medical Management. Ensures quality of service and consistent documentation.
3. Works collaboratively with both internal and external customers in assisting health Plan consumer/beneficiaries' and providers with issues related to prior authorization, utilization management, and/or case management. Meets internal and external customer service expectations regarding duties and professionalism.
4. Performs transfer of accurate, pertinent patient information to support the pre-service determination(s), the transition of patient care needs through the continuum of care, and performs follow-up calls for advanced care coordination. Documents accurately and timely, all interventions and necessary patient related activities in the correct medical record.
5. Evaluates the medical necessity and appropriateness of care, optimizing health Plan consumer/beneficiaries' outcomes. Identifies issues that may delay patient services and refers to case management, when indicated to facilitate resolution of these issues, pre-service, concurrently and post-service.
6. Provides ongoing education to internal and external stakeholders that play a critical role in the continuum of care model. Training topics consist of population health management, evidence based practices, and all other topics that impact medical management functions.
7. Identifies and refers requests for services to the appropriate Medical Director and/or other physician clinical peer when guidelines are not clearly met. Conducts call rotation for the health plan, as well as departmental call rotation for holiday.
8. Maintains a thorough understanding of each plan, including the Evidence of Coverage, Summary Plan Description authorization requirements, and all applicable federal, state and commercial criteria, such as CMS, MCG, and Hayes.
9. Has freedom to determine how to best accomplish functions within established procedures. Confers with supervisor on any unusual situations. Positions are entity based with no budgetary responsibility. Internal customers: All levels of nursing management and staff, medical staff, and all other members of the interdisciplinary health care team. External Customers: Physicians and their office staff, payers, community agencies, provider networks, and regulatory agencies.
Requires Registered Nurse (R.N.) licensure in the state of practice. All license or certification must identify the issuing state or entity, type of licensure and expiration date or evidence that the certification is the type that does not expire. A bachelor's degree or equivalent experience. Requires proficiency level typically achieved with five years of clinical experience.
Must have a working knowledge of care management, acute care and/or home care environments, community resources and resource/utilization management. Must demonstrate critical thinking skills, problem-solving abilities, effective communication skills, and time management skills. Must demonstrate ability to work effectively in an interdisciplinary team format. Must be able to work flexible hours and take rotating call after hours.
Certification(s) related to field, such as Certified Case Manager (CCM), MCG Certification(s), RN-BC Registered Nurse Case Manager, Certification in Managed Care Nursing (CMCN).
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.