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Responsibilities

Under the general direction of the Director of Care Management, performs criteria-based concurrent and retrospective utilization review to support and encourage the efficient and effective use of resources; promote quality patient care; assist with patient care management; comply with applicable standards and regulations and provide information and education to clinical care providers in order to achieve optimal clinical, financial, operational and patient satisfaction outcomes.

Skills needed:

Knowledge of federal, state and managed care rules and regulations including CMS and AHCCCS. Working knowledge with INTERQUAL or Milliman preferred. Excellent written and verbal communication skills with the ability to interact with patients/family, clinical staff, insurance providers and post-acute care providers.

Responsibilities:

+ Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent and post discharge for appropriate status determination.

+ Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.

+ Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers.

+ Ensures timely communication and follow upwith physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.

+ Collaborates with facility RN Care Coordinators to ensure progression of care.

+ Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.

Qualifications

Minimum:

+ Graduate of an accredited school of nursing

+ Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience

+ RN: AZ or Compact License

+ Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used

Preferred:

+ Bachelor's Degree in Nursing (BSN) or related healthcare field

+ At least five (5) years of nursing experience

+ Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification

Overview

**Dignity Health – Arizona General Hospital** located in southeast Mesa on Elliot Rd and Ellsworth Rd is a fully-equipped hospital open 24-hours, 7 days a week, 365 days a year. The facility features an emergency room, capacity for 50 inpatient beds, an Intensive Care Unit, 14 emergency room beds, four operating or procedure rooms, a full onsite laboratory and radiology suite complete with 64 slice CT scan, x-ray, ultrasound capabilities and MRI.

The word “dignity” perfectly defines what our organization stands for: showing respect for all people by providing excellent care. At Arizona General Mesa, our employees are the heart and soul of our organization. They are the reason we are able to live out our healing ministry within the communities we serve. Our doctors, nurses and allied health professionals are a regular self-contained support system for each other. This unique working culture is one of the reasons why a career with us is so rewarding.

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Pay Range

$36.96 - $53.60 /hour

We are an equal opportunity/affirmative action employer.