Summary

The individual in this position is responsible to facilitate effective resource coordination to help patients

achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for

ensuring that care is provided at the appropriate level of care based on medical necessity. This position

manages medical necessity process for accurate and timely payment for services which may require

negotiation with a payer on a case by case basis. This position integrates national standards for case

Management Scope Of Services Including

• Utilization Management services supporting medical necessity and denial prevention
• Coordination with payers to authorize appropriate level of care and length of stay for medically
  
  

necessary services required for the patient

• Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet
  
  

policy

• Education provided to payers, physicians, hospital/office staff and ancillary departments related to
  
  

covered services and administration of benefits

The individual’s responsibilities include the following activities: a) accurate medical necessity screening

and submission for Physician Advisor review, b) securing and documenting authorization for services from

payers, c) managing concurrent disputes, d) collaborating with payers, physicians, office staff and ancillary

departments, e) timely, complete and concise documentation in the Tenet Case Management documentation

system, f) maintenance of accurate patient demographic and insurance information, g) identification and

documentation of potentially avoidable days, h) identification and reporting over and underutilization, i)

and other duties as assigned.

919-910-9801

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.

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Education

• BSN preferred (unless required * if Magnet Hospital)
  
  

Experience

• Required qualifications include an active Registered Nurse license with at least two years acute hospital or Behavioral Health patient care experience
  
  

Certification

• Accredited Case Manager (ACM) preferred.
  
  

Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.