As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

JOB SUMMARY

The Lead Utilization Review nurse leads the Utilization Review staff, including but not limited to: monitoring daily workloads and case assignment, develops and delivers initial and ongoing systems and process training, auditing, coaching, and oversight of the operations to ensure all contract requirements and business initiatives are completed successfully and timely. Lead will be responsible for a owning a small caseload.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• Leads the Utilization Review process of telephonic and electronic chart review of inpatient members.
• Designs and implements orientation, ongoing training and new program implementation.
• Assists in developing clinical and economic outcomes measurement.
• Provides coverage for Case Management staff when necessary.
• Ensures a positive workplace culture promoting Conifer workplace guidelines; confidentiality of patient information and HIPAA regulations
• Determines and documents medical necessity based on Milliman criteria.
• Meets or exceeds established CMDM productivity standards.
• Participates in Medical Services and Concurrent Review Team meetings and work groups.
• Communicates and resolves issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution

SUPERVISORY RESPONSIBILITIES

If direct report positions are listed below, the following responsibilities will be performed in accordance with guidelines, policies and procedures and applicable laws. Supervisory responsibilities include interviewing, hiring, and training employees; planning, assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

• Direct Reports (titles) Utilization Review Nurses

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Experience in Utilization Review.
• Experience utilizing Milliman Criteria.
• Strong critical thinking and problem solving skills.
• Ability to network, advocate, communicate assertively with all customers.
  
• Ability to establish and maintain effective working relationships as required by the duties of the positionExperience working with high volume and strict timeframes.
• Excellent analytical, communication, training and leadership skills.
• Exceptional organizational skills.
• Ability to work in fast paced environment.
• Must work independently as well as part of a team.
• Must have c experience working with Medical Management platform systems including but not limited to; MS Word, Excel, and Outlook
  

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience preferred to perform the job.

• Minimum Education: Associate Degree RN
• Preferred Education: BA or BS in Nursing
• Minimum Experience: 2 Years Insurance Utilization Review, or has exhibited proficiency in all required skills and 2 years Acute Care Experience
  
• Preferred Experience: 5 years Insurance Utilization Review and 5 years Acute Care Experience with 1 year ICU / ER

CERTIFICATES, LICENSES, REGISTRATIONS

• Required: Arizona Unrestricted License
  

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must be able to work in sitting position, use computer and answer telephone
• Includes ability to walk through organization departments
  

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Office Work Environment

OTHER

• Occasional travel may be required

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.