Nurse Reviewer

Job Number
Banner Health (Corporate)
Banner Health (Corporate) - Case Mgmt-Corp
Position Type
FT: Full-Time
Street Address
2901 N. Central Ave
City & State
Posting Category
Nursing - Case Management
New Grad


Banner Health's Utilization Management Resource Department (BHURD). This is the centralized team responsible for validating medical necessity for inpatient admissions or placement in observation. We also work to mitigate potential admission and concurrent denials. This team is heavily engaged in the Clinical Revenue Integrity initiatives. Team members are held accountable to productivity metrics and held to a high level of accuracy.


Requires recent RN bedside experience within 1 yr or case mgt experience.  Needs good organizational mgt skills, comfortable speaking with physicians.


This is a remote position.  Work from home.  Candidate must live within a 2 hour drive from a Banner location in the event of home computer difficulty, candidate will be able to work at a Banner location temporarily until computer difficulties have been resolved.


Additional Preferred Qualifications
Case Management Experience Highly Preferred. Payer experience. InterQual or other evidence-based criteria knowledge. Strong critical thinking skills.Strong computer skills. Ability to make sound decisions. Resourceful. Strong. Team Player.


About Banner Health Corporate
Within Banner Health Corporate, you will have the opportunity to apply your unique experience and expertise in support of a nationally-recognized healthcare leader. We offer stimulating and rewarding careers in a wide array of disciplines. Whether your background is in Human Resources, Finance, Information Technology, Legal, Managed Care Programs or Public Relations, you'll find many options for contributing to our award-winning patient care.



About Banner Health
Banner Health is one of the largest, nonprofit health care systems in the country and the leading nonprofit provider of hospital services in all the communities we serve. Throughout our network of hospitals, primary care health centers, research centers, labs, physician practices and more, our skilled and compassionate professionals use the latest technology to change the way care is provided. The many locations, career opportunities, and benefits offered at Banner Health help to make the Banner Journey unique and fulfilling for every employee.


Job Summary

This position reviews clinical information and conducts audits of billings to determine appropriateness of charges in accordance with contracted payor terms, standards of care and insurance policy parameters. Works with physicians, patients, payors and other healthcare providers support appropriate utilization of healthcare services. Provides clinical knowledge to assist billing and collection team members in responding to insurance denial of billings.


Essential Functions

  • Evaluates and intervenes concurrently and retrospectively for level of care, coverage issues, payor outliers, split billing, disallowed charges, patient inquires, denial and compliance issues.


  • Initiates actions and participates with Patient Financial Services payor teams regarding resolution of denial management issues or compliance issues. Works with authorized payors or reviewers to resolve denial management issues, reconsiderations and appeals.


  • Tracks, monitors and documents denial causes and resolutions with appropriate management staff.


  • Acts as a knowledge resource for billing staff members. Identifies educational needs regarding payor issues, functions as preceptor, and provides appropriate education.


  • Builds and continually updates a knowledge of Third Party Payor requirements for covered treatment protocols by diagnosis, approval requirements for procedures, and coverage norms.


  • Provides education by collaborating with Care Coordination at company facilities or other staff of non-company locations on concurrent and retrospective utilization review. Accurately and thoroughly completes documentation required for claims payment of services approved through concurrent review and case management.



Minimum Qualifications

Requires Registered Nurse (R.N.) licensure in the state of practice. In a Behavioral Health setting requires current Arizona Board of Behavioral Health Examiners License based on an accredited Master's degree.

Requires five or more years of clinical nursing or related experience or in a Behavioral Health setting Master's level Social Work in healthcare, behavioral health counseling, or related experience. Experience in evaluation techniques, teaching, hospital operations, reimbursement methods, medical staff relations, and the charging/billing process is required. A working knowledge of utilization management and patient services is required. A working knowledge of Medical and third party payor requirements and reimbursement methodologies is required.

Highly developed human relation and communication skills are required. Excellent organizational, written and verbal communication skills are essential for this position.

Preferred Qualifications

A Bachelor of Science degree in Nursing is preferred.

Additional related education and/or experience preferred.