Utilization/Clinical Review RN - PRN

Job Responsibilities

• Provides clinical information to insurance companies as needed for completion of pre-certification process.
• Evaluates all patients, including critical care, for appropriateness of admission type and setting.
• Initiates and facilitates physician communications relative to utilization review process.
• Reviews concurrently all inpatients, including critical care, every three days or sooner if payor requests.
• Ensures all pertinent information is documented into various systems for utilization review process.
• Supports organizational efforts to ensure accurate capture of admission status and level of care.
• Serves as resource to Case Management for facilitation of patients moving to appropriate level of care.
• Meets productivity and quality assurance standards.
• Attends all required meetings and participates in department activities.

Requirements

• 3 years of experience in a healthcare setting; pediatrics highly preferred
• Bachelor of Science in Nursing
• 2 years of experience in hospital or insurance related utilization review
• Previous experience with MCG and/or InterQual systems
• Licensure as a Registered Nurse in the State of Georgia

Qualifications

• Working knowledge of financial aspects of third-party payors and reimbursement
• Effective decision-making/problem-solving skills
• Demonstration of creativity in problem-solving
• Above-average computer skills
• Passes the Basic Windows Skill Assessment within 30 days of employment

Skills

• Knowledge of utilization review processes
• Ability to work independently and manage multiple tasks
• Strong communication and interpersonal skills

Benefits

This role is PRN and requires (6) 8-hour days per month with 1 day being on the weekend. Training/Orientation will be 3 days/week (8-hour days) for 8-10 weeks. Onsite Orientation is needed 3-4 days for first week. Some holidays are required as well.

Pay

Details about pay are not specified in this job posting.

Schedule

The role is remote but requires regular meetings/trainings at the Support Center in Atlanta.