RN UR Specialist, In House (Preferred) or Remote

The primary responsibilities of the RN UR Specialist include performing activities related to insurance company notifications, obtaining certifications and authorizations related to Utilization review duties in Care Management. Timely communication of clinical information and updates will be provided to the insurance companies as requested or required by contract or federal and state regulations in support of medical necessity justification and hospital billing and payment for patient care and services rendered.

Responsibilities

• Completes utilization review functions on assigned caseload or area and serves as a resource for CM staff, physicians and other staff.
• Functions as liaison and resource regarding updates in payer requirements and hospital processes.
• Assures appropriate authorizations for patient level of care and works to avert potential payer denials.
• Notifies Physician offices of required notification, precertification, or authorizations as necessary.
• Communicates pertinent clinical information to insurance companies as needed.
• Communicates all relevant information to the appropriate Care Management staff.
• Notifies attending physicians of potential insurance company denials; may take verbal orders for change in patient status.
• Coordinates peer-to-peer physician case review.
• Participates in data collection as directed by the Care Management Director; ensures accuracy, timeliness, and integrity of data.
• Identifies performance improvement opportunities, proposes resolutions, and records on appropriate forms.
• Coordinates with unit Care Managers, Social Workers, and CM staff to assure payer decisions are known and actions taken as needed to prevent denials or patient liability.
• Works closely with Patient Accounts and Revenue Cycle areas to address payer issues and reconciliations of accounts as needed.
• Documents and records review activity, follow-up, and outcomes in the appropriate electronic system; ensures documented information is timely and inclusive of pertinent facts.
• Clearly and accurately documents UM-related reviews, referrals, activities related to utilization review, approvals, denials, avoidable delays, and outcomes.
• Ensures documentation is tailored to expected readers/users and uses correct terminology in accordance with hospital standards.
• Applies medical staff-approved clinical criteria to reviews and in accordance with payer standards and requirements.
• Utilizes applicable payer portals to input clinical information, secure notifications, and approvals.
• Researches sites for updated manuals, bulletins, and requirements; communicates changes within the Care Management department, to Director, and Chief Utilization Officer.
• Engages in teamwork as a team player and a team leader.
• Educates staff, physicians, and patients about the role of UR Specialist and changing payer trends and requirements.
• Serves on committees or participates in projects with opportunities for shared decision-making and being a change agent.
• Promotes professionalism of the role through participation in professional organizations and/or research in utilization management.
• Incorporates evidence-based knowledge in practice.
• Adheres to hospital and departmental attendance and punctuality guidelines.
• Performs all job responsibilities in alignment with the core values, mission, and vision of the organization.
• Performs other duties as required and completes all job functions as per departmental policies and procedures.
• Maintains current knowledge in present areas of responsibility, including any specialty certification requirements.
• Attends staff meetings and completes mandatory in-services, requirements, and competency evaluations on time.
• Demonstrates competency in providing care to all patients based on age, sex, weight, and demonstrated needs.

Requirements

• Associate's Degree in Nursing (Required)
• Bachelor's Degree in Nursing (Preferred)
• 3+ years of recent and relevant acute clinical care experience (Required)
• 1+ years of utilization review experience in a hospital, managed care, or physician office practice setting (Required)

Qualifications

• Registered Nurse (RN) licensure in the state of Georgia (Required)
• Certified Case Manager (Preferred)
• Certified Professional Utilization Review (Preferred)

This position will be on-site.