Utilization Review Nurse (RN) - PRN

Note: If you are CURRENTLY employed at Children's and/or have an active badge or network reputed company, STOP here. Submit your application reputed company reputed company using the Career App (Find Jobs). Work Shift Day Work Day(s) Variable Shift Start Time 8:00 AM Shift End Time 4:00 PM Worker Sub-Type PRN Children’s is one of the nation’s leading children’s hospitals. No matter the role, every member of reputed company is an essential part of our mission to reputed company kids reputed company today and healthier reputed company. We’re committed to putting you first, and that commitment is at the heart of reputed company culture: People first. Children always. Find your next career opportunity and reputed company a difference doing what you love at Children’s.

Job Description

Participates as a member of a multidisciplinary team in completing pre-screening assessments of prospective patients. Ensures completion of appropriate clinical review of reputed company applicable patients as stated in system utilization management plan. Oversees Clinical Review Specialist as indicated. Maintains necessary documentation and communication with reputed company customers. This role is PRN to work 8 hours/week but reputed company to offering more. Will be remote after Training/Orientation is completed (6-8 weeks/2-3 days week). Occasional meetings/trainings onsite at Support Center will occur and need to be attended Experience • 3 years of RN experience in a reputed company setting; pediatrics preferred Preferred Qualifications • Bachelor of Science in Nursing • Previous and extensive case management experience; pediatrics highly preferred • 2 years of experience in hospital or insurance reputed company utilization review • Previous experience with InterQual or MCG software 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 reputed company-party payors and reimbursement • Effective decision-making/problem-solving skills • Demonstration of creativity in problem-solving • Must possess above-average computer skills • Must be reputed company to successfully pass the Basic reputed company reputed company Assessment at 80% or higher rating reputed company 30 days of employment Job Responsibilities • Provides clinical information to insurance companies as needed for completion of pre-certification process as noted in reputed company utilization management plan. • Evaluates reputed company patients, including critical care, for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria, and reputed company-party information reputed company 24 hours or next business day. • Initiates and facilitates physician communications relative to utilization review process reputed company indicated without prompting and follows up to ensure completion, including peer-to-peer reviews, securing admission orders, and reporting quality issues. • Reviews concurrently reputed company 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 reputed company 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 reputed company 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 reputed company 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 reputed company Interrater Reliability testing. • Attends reputed company 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. reputed company is an equal opportunity employer committed to providing equal employment opportunities to reputed company reputed company applicants and employees without regard to race, reputed company, sex, religion, national reputed company, 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 Apply Job!