Overview

Looking to be part of something more meaningful? At HonorHealth, you’ll be part of a team, creating a multi-dimensional care experience for our patients. You’ll have opportunities to make a difference. From our Ambassador Movement to our robust training and development programs, you can select where and how you want to make an impact. HonorHealth offers a diverse benefits portfolio for our full-time and part-time team members designed to help you and your family live your best lives. Visit honorhealth.com/benefits to learn more. Join us. Let’s go beyond expectations and transform healthcare together. HonorHealth is one of Arizona’s largest nonprofit healthcare systems, serving a population of five million people in the greater Phoenix metropolitan area. The comprehensive network encompasses six acute-care hospitals, an extensive medical group with primary, specialty and urgent care services, a cancer care network, outpatient surgery centers, clinical research, medical education, a foundation, an accountable care organization, community services and more. With nearly 17,000 team members, 3,700 affiliated providers and close to 2,000 volunteers dedicated to providing high quality care, HonorHealth strives to go beyond the expectations of a traditional healthcare system to improve the health and well-being of communities across Arizona. Learn more at HonorHealth.com.

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 escalates secondary reviews to Physician Advisor as necessary.
• 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 as a 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