Job Summary and Responsibilities

Under the general direction of the Manager of Utilization Review, 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.
Job Requirements

Minimum:

Graduate of an accredited school of nursingMinimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experienceRN: AZ or Compact LicenseAbility 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 experienceCertified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification Utilization Review experienceWhere You'll Work

Hello Humankindness

Chandler, Arizona,has a stable suburban population with an economy anchored by many large financial, and high tech companies. Located southeast of Phoenix, Chandler is a skillfully developed community of friendly, diverse neighborhoods with expansive parks, great schools, convenient shopping, and excellent career opportunities.

For more than 50 years, Dignity Health’s Chandler Regional Medical Center has focused on quality patient care and service to the community. As the longest established hospital in the southeast valley, Chandler Regional has provided care for the Chandler community since 1961. The hospital recently added a new five-story tower with 96 patient beds, increasing the acute-care bed count to 338. This expansion increased emergency and trauma services, as well as the surgical unit and intensive care offerings. 

The word “dignity” perfectly defines what our organization stands for: showing respect for all people by providing excellent care. At Chandler Regional, 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. 

Now is the perfect time to come grow your career with one of Arizona's Most Admired Companies.

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Total Rewards

Depending on the position offered, CommonSpirit Health offers a generous benefit package, including but not limited to medical, prescription drug, dental, vision plans, life insurance, paid time off (full-time benefit eligible team members may receive a minimum of 14 paid time off days, including holidays annually), tuition reimbursement, retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings, as may be amended from time to time. For more information, please visit our Total Rewards

Unless directed by a Collective Bargaining Agreement, applications for this position will be considered on a rolling basis. CommonSpirit Health cannot anticipate the date by which a successful candidate may be identified.