Registered Nurse (RN) - Utilization Review

The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optima lhealth, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination.

The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case-by-case basis. This position integrates national standards for

case management scope of services including:

• Utilization Management services supporting medical necessity and denial prevention
• Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient
• Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
• Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits
• Other related duties as assigned

Qualifications

Minimum Education

Graduate of an accredited School of Nursing PREFERRED EDUCATION: Bachelors or Masters Degree in Nursing MINIMUM EXPERIENCE: 2 years acute hospital or behavioral health patient care experience with at least 1 year utilization review in an acute hospital or commercial/managed care payer setting.

Preferred Experience

Previous Case Management Supervisory experience.

Required Certifications/Licensure

Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN license for state(s) covered.

Preferred Certifications/Licensure

Accredited Case Management (ACM) REQUIRED COURSES/ COMPLETIONS: Must complete Tenet’s InterQual® education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better.

Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire. Orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQual®, Utilization Management, and other topics specific to case management.

Join our dedicated healthcare team where compassion meets innovation! As a Registered Nurse with us, you'll have the opportunity to make a meaningful impact in patients' lives while enjoying a supportive work environment that fosters professional growth and work-life balance. Ready to be a vital part of our mission? Apply today and bring your passion for nursing to a place where it truly matters!

At Baptist Health System, we understand that our greatest asset is our dedicated team of professionals. That’s why we offer more than a job – we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include:

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Note: Eligibility for benefits may vary by location and is determined by employment status: Baptist Health System has more than 120 years history of caring for our community and making a positive difference.

Our system of care includes six full-service hospitals, a specialized childrens hospital with a dedicated pediatric emergency unit, a comprehensive cancer care network, fitness and rehabilitation centers, a physician network, imaging centers, ambulatory services and the Baptist School of Health Professions.

Wherever you go in the Baptist Health System, youll find that we have the same goal to help people achieve health for life through compassionate service inspired by faith. Join our team!