Clinical Review/Utilization Nurse

1 month ago

Brookhaven, United States Children's Healthcare of Atlanta Full time
Job Description

Note: If you are CURRENTLY employed at Children's and/or have an active badge or network access, STOP here. Submit your application via Workday using the Career App (Find Jobs).

Work Shift

Variable

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 our team is an essential part of our mission to make kids better today and healthier tomorrow. We’re committed to putting you first, and that commitment is at the heart of our company culture: People first. Children always. Find your next career opportunity and make 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 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 to work 8 hours/week but open to offering more. Will be remote after Training/Orientation is completed (6-8 weeks for 2-3 days week). Occasional meetings/trainings to be held onsite at Support Center.

Experience

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

Preferred Qualifications

  • Bachelor of Science in Nursing
  • Extensive case management experience highly preferred
  • 2 years' experience in hospital or insurance related utilization review
  • Prior experience with Milliman and/or InterQual highly preferred

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

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