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Great careers are built at Banner Health. There's more to health care than doctors and nurses. We support all staff members as they find the path that's right for them. Apply today, this could be the perfect opportunity for you.
Banner Health's Utilization Management Review Department (BHURD) is seeking an RN Reviewer to join their team! As an integral part of this centralized team, you would be responsible for validating medical necessity for inpatient admissions or placement in observation. You would also work to mitigate potential admission and concurrent denials. You will be heavily engaged in the Clinical Revenue Integrity initiatives by working in conjunction with providers and payers. Team members are held accountable to productivity metrics and held to a high level of accuracy.
Within 30 days of hire, all new hires/transfers, are required to apply for and maintain multistate licensures for states we perform work in (AZ - must be compact: CA, CO, NV).
Your pay and benefits are important components of your journey at Banner Health. Banner Health offers a variety of benefits to help you and your family. We provide health and financial security options so you can focus on being the best at what you do and enjoying your life.
If you are a New Graduate Nurse with less than 12 months of experience, please visit the main job search page and under the Job Type filter, select New Nurse Experience.
Within Banner Health Corporate, you will have the opportunity to apply your unique experience and expertise in support of a nationally-recognized healthcare leader. We offer stimulating and rewarding careers in a wide array of disciplines. Whether your background is in Human Resources, Finance, Information Technology, Legal, Managed Care Programs or Public Relations, you'll find many options for contributing to our award-winning patient care.
POSITION SUMMARY This position reviews clinical information and conducts audits of billings to determine appropriateness of charges in accordance with contracted payor terms, standards of care and insurance policy parameters. Works with physicians, patients, payors and other healthcare providers support appropriate utilization of healthcare services. Provides clinical knowledge to assist billing and collection team members in responding to insurance denial of billings.
CORE FUNCTIONS 1. Evaluates and intervenes concurrently and retrospectively for level of care, coverage issues, payor outliers, split billing, disallowed charges, patient inquires, denial and compliance issues.
2. Initiates actions and participates with Patient Financial Services payor teams regarding resolution of denial management issues or compliance issues. Works with authorized payors or reviewers to resolve denial management issues, reconsiderations and appeals.
3. Tracks, monitors and documents denial causes and resolutions with appropriate management staff.
4. Acts as a knowledge resource for billing staff members. Identifies educational needs regarding payor issues, functions as preceptor, and provides appropriate education.
5. Builds and continually updates a knowledge of Third Party Payor requirements for covered treatment protocols by diagnosis, approval requirements for procedures, and coverage norms.
6. Provides education by collaborating with Care Coordination at company facilities or other staff of non-company locations on concurrent and retrospective utilization review. Accurately and thoroughly completes documentation required for claims payment of services approved through concurrent review and case management.
7. Works independently under limited supervision. Makes independent judgments based on specialized knowledge. Holds Facility or Regional responsibility for audited and denied billing issues. Internal customers: Patient/family, medical staff, case managers, nursing, social workers, patient services/placement/finances/audit, emergency department, clinic and all other departments and ancillary/support services. External customers: Medical Directors/payors/reviewers, contracted review agencies, other facilities/services, physician's offices.
MINIMUM QUALIFICATIONS Requires Registered Nurse (R.N.) licensure in the state of practice. In a Behavioral Health setting requires Registered Nurse (R.N.) licensure in the state of practice or a current Arizona Board of Behavioral Health Examiners License based on an accredited Master's degree.
Requires five or more years of clinical nursing or related experience or, in a Behavioral Health setting, Master's level Social Work in healthcare, behavioral health counseling, or related experience. Experience in evaluation techniques, teaching, hospital operations, reimbursement methods, medical staff relations, and the charging/billing process is required. A working knowledge of utilization management and patient services is required. A working knowledge of Medical and third party payor requirements and reimbursement methodologies is required.
Employees working at BUMG, BUMCT, or BUMCS in a Behavioral Health clinical setting that serves children must possess an Arizona Fingerprint Clearance Card at the time of hire and maintain the card for the duration of their employment. Employees working at Banner Behavioral Health Hospital or BTMC Behavioral must possess an Arizona Fingerprint Clearance Card at the time of hire and maintain the card for the duration of their employment.
Highly developed human relation and communication skills are required. Excellent organizational, written and verbal communication skills are essential for this position.
A Bachelor of Science degree in Nursing is preferred.
Additional related education and/or experience preferred.
What might draw you to Banner Health? A great health care career, of course—and a great place to live, no matter what stage of life you’re in. With facilities across the West, there is a health care career for everyone, from big city living in the Phoenix area to friendly small towns in the mountains and plains. As one of the largest nonprofit health systems in the country, Banner Health offers both the stability that comes with success and the possibility of exploring new areas of the country. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages:
Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health.
Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible.
The size, success and growth of our system provide you with the stability and options to pursue your desired career path.
Competitive compensation and comprehensive benefits offer you options to complement your unique needs.