RN Utilization Review Case Management Full Time Days Position Days
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:
Responsibilities
THE RN UTILIZATION REVIEW CASE MANANAGEMENT FULL TIME DAYS CANDIDATE WILL POSSESS THE FOLLOWING EDUCATION, LICENSE/CERTIFICATIONS, AND EXPERIENCE.
Education
Required: Graduate of an accredited school of nursing.
Preferred: Academic degree in nursing (bachelor's or master's)
Experience
Required: 2 years pf 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.
Certification
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).
Tenet Healthcare complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.
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)
Physical Demands:
Lift/position up to 25 lbs. Push/pull up to 25 lbs.of force. Frequent sitting. Moderate standing, walking, reaching, stooping, and bending. Manual dexterity, mobility, touch, auditory to perform all the related duties of the position.
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.
Who We Are
We are a community built on care. Our caregivers and supporting staff extend compassion to those in need, helping to improve the health and well-being of those we serve, and provide comfort and healing. Your community is our community.
Our Story
We started out as a small operation in California. In May 1969, we acquired four hospitals, some additional care facilities and real estate for the future development of hospitals. Over the years, we've grown tremendously in size, scope and capability, building a home in new markets over time, and curating those homes to provide a compassionate environment for those entrusting us with their care.
We have a rich history at Tenet. There are so many stories of compassionate care; so many "firsts" in terms of medical innovation; so many examples of enhancing healthcare delivery and shaping a business that is truly centered around patients and community need. Tenet and our predecessors have enabled us to touch many different elements of healthcare and make a difference in the lives of others.
Our Impact Today
Today, we are leading health system and services platform that continues to evolve in lockstep with community need. Tenet's operations include three businesses - our hospitals and physicians, USPI and Conifer Health Solutions.
Our impact spreads far and deep with 65 hospitals and approximately 510 outpatient centers and additional sites of care. We are differentiated by our top notch medical specialists and service lines that are tailored within each community we serve. The work Conifer is doing will help provide the foundation for better health for clients across the country, through the delivery of healthcare-focused revenue cycle management and value-based care solutions.
Together as an enterprise, we work to save lives and can accept nothing less than excellence from ourselves in service of our patients and their families, every day.
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