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Clinical Utilization Review Nurse
2 months ago
Children's Healthcare of Atlanta is seeking a skilled Clinical Utilization Review Nurse to join our team. As a key member of our healthcare team, you will be responsible for ensuring the efficient and effective use of healthcare resources.
Key Responsibilities- Evaluate patients 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.
- Initiate and facilitate 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.
- 3 years of RN experience in a healthcare setting; pediatrics preferred
- Bachelor of Science in Nursing
- ~ 2 years' experience in hospital or insurance related utilization review
- ~ Graduation from an accredited school of nursing
- Working knowledge of financial aspects of third-party payors and reimbursement
- 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
- A dynamic and supportive work environment
- Opportunities for professional growth and development
- A competitive salary and benefits package
