Job Description

Under the direction of the Manager or Director of Care Management, the RN Utilization Review Coordinator is part of the interdisciplinary team and serves as the expert in utilization management. This position is responsible for determining the appropriateness of hospital admissions and medical necessity for continued stay, assuring medical documentation accurately reflects the severity of illness and acuity of the patient. This requires a proficiency in clinical criteria, evidence based practice, regulatory compliance, reimbursement sources, and the health care delivery system.  The RN Utilization Review Coordinator is responsible for assuring the appropriate use of resources, and facilitating the patient's progression through the continuum of care in a timely and cost-effective manner. This position works with managed care plans, third party payers, the business office and the interdisciplinary team to ensure authorization for reimbursement at the appropriate level is confirmed to ensure payment of expected reimbursement.

 

Qualifications:

 

Education:

  • Prefer a Bachelor's degree in Nursing.

Experience:

  • Must have at least three (3) years of recent acute clinical RN hospital experience, preferably in Case Management and/or Utilization Management.

Specialized Training:

  • Trained in Epic, InterQual, Midas and internally used software programs is strongly preferred.

Certification/Licensure:

  • Must possess current valid Arizona RN licensure and be in good standing with the AZ Board of Nursing.
  • Specialty certification in utilization or case management must be obtained within 30 months of hire.

Knowledge, Skills & Abilities:

  • Must have a working knowledge of case management, hospital, community resources and resource/utilization management.
  • The position requires excellent communication and clinical skills and ability to maintain professional rapport with physicians.
  • Requires extensive knowledge of evidence based clinical guidelines, best practice, workup, treatment, prognosis and hospital procedures.
  • Critical thinking ability essential.
  • Strong critical care skills, understanding of medical documentation and pathophysiology.
  • Knowledge of acute care criteria sets and state and federal reimbursement programs.
  • Requires the ability to read, write and speak effectively in English.

Application Instructions

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