Banner Health Registered Nurse Medical Management Services in Phoenix, Arizona

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If you are a New Graduate Nurse with less than 12 months of experience, please apply to our.

Registered Nurse Medical Management

The Medical Management Services Department is responsible for execution on strategies that support right setting, right service and right cost for Banner Health Network populations utilizing levers such as prior authorization, concurrent and post - acute management as well as claims review. The Prior Authorization Department processes medical service requests for Banner Choice Plus and Select Plans, Banner Health Network, i.e., Medicare Advantage or Commercial Plans.

Qualifications:

  • 5 years in nursing experience in hospital setting

  • Health care knowledge including commercial and Medicare/Medicaid health plans

  • ICD-10 and CPT Coding knowledge

  • Computer skills, Microsoft skills, Internet skills

Location:

This position will be located at Banner-Mesa

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About Banner Health Network & Banner Plan Administration

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.

About Banner Health

Banner Health is one of the largest, nonprofit health care systems in the country and the leading nonprofit provider of hospital services in all the communities we serve. Throughout our network of hospitals, primary care health centers, research centers, labs, physician practices and more, our skilled and compassionate professionals use the latest technology to change the way care is provided. The many locations, career opportunities, and benefits offered at Banner Health help to make the Banner Journey unique and fulfilling for every employee.

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Job Summary

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.

Essential Functions

  • Manages health Plan consumer/beneficiaries across the health care continuum to achieve optimal clinical, financial, operational, and satisfaction outcomes.

  • Provides pre-service determinations, concurrent review, and case management functions within Medical Management. Ensures quality of service and consistent documentation.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

Minimum Qualifications

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 bachelors degree or equivalent experience. Requires proficiency level typically achieved with 5 years of clinical experience. Basic Life Support (BLS) certification is also required.

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.

Preferred Qualifications

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.

Job Number 203976

Facility Banner Health Network & Banner Plan Administration

Shift Day

Department Banner Health Network & Banner Plan Administration - Prior Authorization

Position Type FT: Full-Time

Internal Code A ..

Street Address 1441 N. 12th St.

Internal Code B ..

City & State US-AZ-Phoenix

Posting Category Quality

New Grad No