Provides oversight of the utilization review, prior authorization and case management staff and activities as directed by the Manager, Medical Management. Hires, trains and develops staff, evaluates performance and makes recommendation for improvement. Provides leadership and guidance to staff and management.
Leads and manages prior authorization, concurrent review, and case management staff within Medical Management in metropolitan and rural communities. Ensures quality of service and consistency is maintained. Develops workflows and processes that support accurate and timely responses to issues.
Participates in hiring, orientation, and training of staff within the Medical Management Programs. Hires, trains, orientates, develops, and evaluates employees. Evaluates performance and makes recommendations for improvement.
Communicates with PA, CM and UM departmental staff and management to ensure that there is implementation of new desk tops and policies to comply with AHCCCA, CMS and HCGA requirements and Health Plan goals. Develops work standards for area functions. Monitors processes and implements changes as needed for efficiency.
Collaborates with Management staff and Medical Directors to review cases and data for appropriateness of care, resource care, and achievement of budgetary targets.
Conducts audits and routine performance reviews.
Participates in or coordinates rounds, departmental meetings, quality teams, and other committees to ensure collaboration with other departments and compliance with State mandates.
Performs other related duties, including on-call, as assigned, and which are consistent with the goals and qualifications of this position.
Knowledge and experience as typically obtained by the completion of an Associates degree in Nursing.
Current AZ RN license permitting work in the State of Arizona.
Three years of clinical RN experience in prior authorization, utilization review, or case management, with one year of experience in a supervisory or management role. Knowledge of utilization management data analysis.Knowledge of Medicare, Medicaid, and Managed Care, CPT, ICD-9 and HCPCS codes.Skill in preparing and presenting detailed information to ensure understanding for a wide audience base.Skill in organizing work and providing critical thinking to resolve problems.Skill in communicating with all levels of the organization.Skill in conducting utilization data analysis and providing recommendations.Skill in oral and written communication.Ability to organize and execute programs.Ability to work independently to identify, develop, monitor, evaluate, and report on projectsAbility to perform ongoing and objective projects ensuring all deadlines are met.Ability to be flexible in order to work on a variety of initiatives simultaneously under tight time constraints.Ability to build and maintain professional working relationships with all levels of support staff, providers, administrative staff and all internal and external customers.
Skill in computer applications including Microsoft Office Products and other medical management systems.
Additional related education and/or experience preferred.
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •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 system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •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. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.