Job Description

Our Mission:  Provide the best value in health insurance and related health services to improve the quality of life for Arizonans.

Our Vision: 

Inspire health in Arizona as the trusted leader in delivering affordable, innovative healthcare solutions.

Our Benefits: Our benefits provide work-life balance and the flexibility you need to be your best. We offer comprehensive medical, dental, and vision coverage; a 401K savings plan; paid holidays and vacations; and much more!

Position Purpose:  The Utilization Review Nurse completes inpatient admission and concurrent reviews for Health Choice members, considering InterQual criteria and other national standards, Policy and Procedures, and the member’s medical benefits.  Reviews are made telephonically and via fax.   Assists and coordinates the discharge planning needs of the member with the facility staff, attending physician, the member, and his/her support. 

Responsibilities:

  • Review all inpatient admissions and initiate discharge planning in a timely manner
  • Review complex, high dollar and lengthy stay admissions
  • Assist with transplant admissions and pre-transplant authorizations
  • Complete NICU inpatient reviews and continued stay reviews
  • Utilize clinical skills, chart review, PHY communication, and InterQual standards for approval of inpatient stay
  • Conduct ongoing review for members in inpatient stay including reviewing requested procedures, DME, home health or pharmaceutical needs while inpatient or upon discharge utilizing peer review, as necessary
  • Communicate with Medical Director(s) for determination on reviews that do not meet criteria
  • Provide notification to facility of determination
  • Facilitate member’s transfers within contract facilities for ongoing inpatient stays
  • Complete documentation in medical management system
  • Initiate interdepartmental coordination to ensure quality and timely care for members
  • Coordinate discharge planning to create member’s post-inpatient plan
  • Interact with social worker, community agencies to identify alternate delivery of services
  • Evaluate the need for case management  and transition of care services following inpatient stay
  • Coordinate transportation with contracted vendors following inpatient stay

Education / Experience / Other Requirements

Education:   

  • Associate’s degree or Bachelor’s degree from an accredited Nursing School required (Remote position available.  Must be a resident of Arizona)
  • Current AZ nursing license

Years of Experience:  

  • Previous UR/Discharge planning experience preferred
  • Previous Medicaid/Medicare experience preferred  

Specialized Knowledge:  

  • InterQual criteria
  • Strong knowledge of care management and care coordination
  • Proficiency in computer and technology required, including, but not limited to: medical management software, data-analytics software, Microsoft Office Products (Outlook, Excel, Power Point, Word, Visio)

Skills & Abilities:

  • Ability to manage multiple projects and prioritize adhere to deadlines/time frames
  • Complete tasks with little supervision
  • Ability to manage large workload

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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