Nurse Utilization Review at CommonSpirit Health

Where Youll WorkHello humankindnessLocated conveniently in the heart of Phoenix Arizona St. Josephs Hospital and Medical Center is a 571-bed not-for-profit hospital that provides a wide range of health social and support services. Founded in 1895 by the Sisters of Mercy St. Josephs was the first hospital in the Phoenix area. More than 125 years later St. Josephs remains dedicated to its mission of caring for the poor and underserved. We are extremely proud to be a nationally recognized center for quality quaternary care medical education and research. St. Josephs includes the internationally renowned Barrow Neurological Institute Norton Thoracic Institute Cancer Center at St. Josephs Ivy Brain Tumor Center and St. Josephs Level I Trauma Center (which is verified by the American College of Surgeons). The hospital is also a respected center for high-risk obstetrics neuro-rehabilitation orthopedics and other medical services. St. Josephs is considered a sought-after destination hospital for treating the most complex cases from throughout the world. Every day approximately 20 percent of the hospitals patients have traveled from outside of Arizona and the United States to seek treatment at St. Josephs.U.S News & World Report routinely ranks St. Josephs among the top hospitals in the United States for neurology and addition St. Josephs boasts the Creighton University School of Medicine at St. Josephs and a strategic alliance with Phoenix Childrens Hospital.St. Josephs is consistently named an outstanding place to work and one of Arizonas healthiest employers. Come grow your career with one of Arizonas Most Admired Companies.Look for us on Facebook and follow us on Twitter.For the health of our community ... we are proud to be a tobacco-free campus.Job Summary and ResponsibilitiesUnder 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 up with 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 RequirementsMinimum: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) usedPreferred:Bachelors Degree in Nursing (BSN) or related healthcare fieldAt least five (5) years of nursing experienceCertified Case Manager (CCM) Accredited Case Manager (ACM-RN) or UM CertificationUtilization Review experience Key Skills EMR Systems,Hospital Experience,Acute Care,ICU Experience,Dermal Fillers,Experience Administering Injections,Home Care,Nursing,Botox Experience,Critical Care Experience,Medication Administration,Tube Feeding Employment Type : Unclear Experience: years Vacancy: 1