Clinical Review/Utilization Nurse Specialist

3 weeks ago


Brookhaven, Georgia, United States Children's Healthcare of Atlanta Full time
Job Title: Clinical Review/Utilization NurseJob Summary:

We are seeking a skilled Clinical Review/Utilization Nurse to join our team at Children's Healthcare of Atlanta. As a key member of our multidisciplinary team, you will be responsible for completing pre-screening assessments of prospective patients and ensuring the completion of appropriate clinical reviews. Your expertise will be essential in maintaining necessary documentation and communication with internal and external customers.

Responsibilities:
  • Participate in the completion of pre-screening assessments of prospective patients.
  • Ensure the completion of appropriate clinical reviews of all applicable patients.
  • Maintain necessary documentation and communication with internal and external customers.
  • Support organizational efforts to ensure accurate capture of admission status and level of care.
  • Refers denied cases to appropriate personnel and provides assistance and/or clinical support to aid in appeal process.
Requirements:
  • 3 years of RN experience in a healthcare setting; pediatrics preferred.
  • 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.
Preferred Qualifications:
  • Licensure as a Registered Nurse in the single State of Georgia or Multi-State through the Enhanced Nurse Licensure Compact.
  • 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.
What We Offer:

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.



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