Utilization Management Nurse

ArchWell Health - Phoenix, AZ

Job Title: Utilization Management Nurse

Position: Nurse responsible for ensuring appropriate, cost-effective patient care

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City: Phoenix

State: AZ

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Conducts prospective, concurrent, and retrospective utilization reviews for medical necessity to ensure treatment and services are appropriate and necessary by reviewing medical records and treatment plans.
Works collaboratively with healthcare providers and Medical Directors to provide guidance on approvals or requests for health plan determination reviews as applicable utilizing CMS clinical guidelines and insurance policies.
Maintains accurate and detailed records of reviews, interventions, and communications to ensure adherence to health plan requirements and organizational policies.
Analyzes utilization trends to ensure progress towards organizational goals.
Educates healthcare providers and patients regarding appropriate levels of care and service criteria and guidelines.
Collaborates with Network and specialists to identify opportunities to educate on value-based care, resolve specialty gaps by markets, improve cost-effectiveness and coordination of care to meet patient needs.

Strong knowledge of utilization management functions in value-based care, including data analysis, claims review, reimbursement practices, and medical records reviews.
Thorough, in-depth knowledge of evidence-based practice, legal rules and regulations and best practices in healthcare.
Excellent critical reasoning, decision-making, and problem-solving skills.
Ability to effectively leverage business and organizational knowledge within and across functional areas.
High degree of emotional intelligence and integrity.
Self-starter with the ability to think creatively and work effectively.

Fluency in Spanish or other languages spoken by people in the communities served
Proficient PC skills

Experience: A minimum of 3 years’ current direct utilization management required.

Education: AA/AS degree in Nursing required; BA/BS degree in Nursing (BSN) or Healthcare Administration preferred.

License & Certification:

A valid, active Registered Nurse (RN) license in state(s) of employment required.

Schedule:

COVID-19 Requirements: Not Specified

ArchWell Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to their race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected classification.