RN Medical Management

Better Than Ever for Nurses. At Banner Health, advanced technology and nursing come together to achieve the best patient care possible. We’re making the biggest investment ever in creating a better employment experience for our nursing team members.

As a RN Medical Management, you will focus on prior authorization. In this desk-based role, you will review cases using clinical guidelines, collaborate with providers, and document prior auth activities to support quality outcomes and cost-effective care. Daily responsibilities include frequent use of Microsoft Outlook, Teams and Word, participation in meetings, and independent case reviews. Ideal candidates have experience in prior authorization or utilization management, experience using CareWebQI/InterQual, possess a strong clinical background, and are comfortable working in a remote environment.

POSITION SUMMARY
This position 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.

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

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

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. Has freedom to determine how to best accomplish functions within established procedures. Confers with supervisor on any unusual situations. Positions are entity based with no budgetary responsibility. Internal customers: All levels of nursing management and staff, medical staff, and all other members of the interdisciplinary health care team. External Customers: Physicians and their office staff, payers, community agencies, provider networks, and regulatory agencies.

EEO/Disabled/Veterans

Our organization supports a drug-free work environment.

Privacy Policy