Registered Nurse Clinical Information Specialist

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Join Banner Health's Utilization Review Department (BHURD) as a fully remote RN, where your acute bedside expertise will directly impact patient care across our entire health system. With a minimum of 5 years of hands-on nursing experience, you'll conduct critical medical and surgical reviews for patients at all Banner facilities, applying evidence-based guidelines to ensure appropriate care status and collaborating with providers on clinical decisions. This isn't your typical remote role—you'll be part of a highly motivated, experienced team with an exceptional retention rate of less than 1%, working independently while meeting daily metrics that drive meaningful outcomes. Enjoy the flexibility of working from home while receiving comprehensive support through our robust 12-week one-on-one preceptorship program, complete with weekly check-ins and clear success milestones. If you're a seasoned acute care nurse ready to leverage your clinical judgment in a new way, contribute to system-wide quality initiatives, and join a stable, high-performing team that values expertise and accountability, this opportunity offers the perfect blend of autonomy, impact, and work-life balance.

SCHEDULE:

• Full Time / 40 Hours
• 10 hour day or evenings
• Every 3rd weekend assigned

LOCATION:

• Hybrid ( Must live in one of the following states: AZ, CO, NE, NV, WY)

PREFERRED QUALIFICATIONS: 5 years of acute bedside nursing, Payer experience MCG or other evidence-based criteria knowledge, Strong critical thinking,  Strong computer skills,  Ability to make sound decisions autonomously, Resourceful, Strong Team Player

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.

Highly developed human relation and communication skills are required. Excellent organizational, written and verbal communication skills are essential for this position.

Employees working at Banner Behavioral Health Hospital, BTMC Behavioral, and 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. An Arizona Criminal History Affidavit must be signed upon hire. Employees working in the Banner McKee Senior Behavioral Health Inpatient Unit must possess a Colorado Fingerprint Clearance Card at the time of hire and maintain the card for the duration of their employment. Employees working in any Banner Staffing (BSS) Behavioral Health role in Arizona must possess a State of Arizona Department of Public Safety Level One Fingerprint Clearance Card at the time of hire and maintain the card for the duration of their employment.

PREFERRED QUALIFICATIONS

A Bachelor of Science degree in Nursing is preferred.

Additional related education and/or experience preferred.

EEO/Disabled/Veterans

Our organization supports a drug-free work environment.

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