Registered Nurse (RN) - Utilization Review

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: Utilization Management services supporting medical necessity and denial prevention; Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient; Compliance with state and federal regulatory requirements, TJC accreditation standards, and Tenet policy; and Education provided to payers, physicians, hospital/office staff, and ancillary departments related to covered services and administration of benefits.