Registered Nurse - Utilization Management

Work at Home

Job Description

Possesses wide range of knowledge in medical complexity, which includes: case management, appeals, denials, utilization management, clinical, medical necessity and complex cases.


  • Provide Pre-Service Determinations, Concurrent Review, and Case Managment functions within Medical Management
  • Ensures quality of service and consistent documentation
  • Collaboratively interact with both internal and external customers, and assist Health Plan and Providers with issues related to Prior Authorization, Utilization Management, and/or Case Management
  • Perform transfer of accurate, pertinent patient information to support the Pre-Service Determination(s), the transition of Patient Care needs through the continuum of care, and performs follow-up calls for advanced care coordination.
  • Documents accurately and timely, all interventions and necessary patient related activities in the correct medical record
  • Evaluates the medical necessity and appropriateness of care, optimizing health Plan outcomes. Identifies issues that may delay patient services and refers to case management, when indicated to facilitate resolution of these issues, pre-service, concurrently and post-service.
  • Provides ongoing education to internal and external stakeholders that play a critical role in the continuum of care model. Training topics consist of population health management, evidence based practices, and all other topics that impact medical management functions.
  • Maintains a thorough understanding of each plan, including the Evidence of Coverage, Summary Plan Description authorization requirements, and all applicable federal, state and commercial criteria, such as CMS, MCG, and Hayes
  • Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Banner Health with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day

Basic Qualifications

  • Active Registered Nurse Certification or Compact State Licensure required
  • Associates Degree 
  • 5 Years Clinical Experience 
  • Must have knowledge of Government/Community agencies and resources, such as Medicare/Medicaid, Long Term Care or other applicable resources/services
  • Must demonstrate effective communication and customer service skills, human relation skills and time management skills
  • Must be able to work flexible hours and work weekends on rotation
  • Must have a working knowledge of ICD-9, CPT, Medical Necessity criteria (such as MCG, InterQual, CMS or Medicaid)
  • BLS required. (BLS is not required for employees working in the Insurance Division)
  • Previous experience in health care service setting, interacting with patients and families, usually obtained through work in social services, as a licensed practical nurse or in a discharge planning setting

Preferred Qualifications

  • Certification(s) related to field, such as Certified Case Manager (CCM), MCG Certification(s), RN-BC Registered Nurse Case Manager, Certification in Managed Care Nursing (CMCN).
  • BSN preferred