Utilization/Clinical Review RN - PRN

Utilization Review Nurse

Participates as a member of a multidisciplinary team in completing pre-screening assessments of prospective patients. Ensures completion of appropriate clinical review of all applicable patients as stated in system utilization management plan. Oversees Clinical Review Specialist as indicated. Maintains necessary documentation and communication with internal and external customers. This role is PRN and requires (6) 8-hour days per month with 1 day being on the weekend. We'll be open to offering more if possible. 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. This role will be remote but regular meetings/trainings will require being onsite at the Support Center in Atlanta.

Experience

• 3 years of experience in a healthcare setting; pediatrics highly preferred

Preferred Qualifications

• Bachelor of Science in Nursing
• 2 years of experience in hospital or insurance related utilization review
• Previous experience with MCG and/or InterQual systems

Education

• Graduation from an accredited school of nursing

Certification Summary

• Licensure as a Registered Nurse in the single State of Georgia or Multi-State through the Enhanced Nurse Licensure Compact

Knowledge, Skills, and Abilities

• Working knowledge of financial aspects of third-party payors and reimbursement
• Effective decision-making/problem-solving skills
• Demonstration of creativity in problem-solving
• Must possess above-average computer skills
• Must be able to successfully pass the Basic Windows Skill Assessment at 80% or higher rating within 30 days of employment

Job Responsibilities

• Provides clinical information to insurance companies as needed for completion of pre-certification process as noted in Children's Healthcare of Atlanta utilization management plan.
• Evaluates all patients, including critical care, for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria, and third-party information within 24 hours or next business day.
• Initiates and facilitates physician communications relative to utilization review process when indicated without prompting and follows up to ensure completion, including peer-to-peer reviews, securing admission orders, and reporting quality issues.
• Reviews concurrently all inpatients, including critical care, every three days or sooner if payor requests, including information regarding patient's medical condition, intensity of services being utilized, treatment plan, and established review criteria.
• Ensures all pertinent information is documented into various systems for utilization review process.
• Gathers and reviews relevant medical information and documents utilization review process outcome based on system accepted utilization criteria on the accepted current review forms and in computer systems.
• Supports organizational efforts to ensure accurate capture of admission status and level of care using Epic and escalating cases for status change where necessary.
• Refers denied cases to appropriate personnel and provides assistance and/or clinical support to aid in appeal process.
• Serves as resource to Case Management for facilitation of patients moving to appropriate level of care and notifying when patients no longer meet medical necessity to aid in discharge planning.
• Meets productivity (10-12 reviews/day) and quality assurance (95%) standards and demonstrates utilization review proficiency with the successful completion and passing of McKesson Interrater Reliability testing.
• Attends all required onsite, telephonic, and mandatory department meetings.
• Participates in department activities to help promote utilization review process, aids in denial prevention, and serves as resource to peers and team members.

Children's Healthcare of Atlanta is an equal opportunity employer committed to providing equal employment opportunities to all qualified applicants and employees without regard to race, color, sex, religion, national origin, citizenship, age, veteran status, disability or any other characteristic covered by applicable law.

Primary Location Address: 1575 Northeast Expy NE

Job Family: Nursing-Non Bedside