[Hiring] Utilization Review Specialist @Phoebe Putney Health System

Role Description

The primary responsibilities of the RN UR Specialist include performing activities related to insurance company notifications, obtaining certifications and authorizations related to Utilization review duties in Care Management. Timely communication of clinical information and updates will be provided to the insurance companies as requested or required by contract or federal and state regulations in support of medical necessity justification and hospital billing and payment for patient care and services rendered.

• Liaison with third party payers regarding UR requirements, authorization or denial matters.
• Assist with complex authorization needs impacting patient transition planning.
• Proactive communication with Care Manager and Social Work staff to foster coordination and a team approach for key care management functions and meeting patient needs.
• Notify Care Managers of potential denials and communicate with patient physician and payer medical director for peer to peer discussions.

Qualifications

• 2 year / Associate Degree in Nursing (Required)
• 4 year / Bachelor's Degree in Nursing (Preferred)
• 4 - 5 years Recent and relevant acute clinical care experience (Required)
• 1 - 2 years Utilization review experience in a hospital, managed care or physician office practice setting (Required)
• Registered Nurse (RN) with current Georgia license (Required)
• CCM or CPUR (Preferred)

Requirements

• Adheres to the hospital and departmental attendance and punctuality guidelines.
• Performs all job responsibilities in alignment with the core values, mission and vision of the organization.
• Performs other duties as required and completes all job functions as per departmental policies and procedures.
• Maintains current knowledge in present areas of responsibility (i.e., self-education, attends ongoing educational programs).
• Attends staff meetings and completes mandatory in-services and requirements and competency evaluations on time.
• Demonstrates competency at all levels in providing care to all patients based on age, sex, weight, and demonstrated needs.
• For non-clinical areas, has attended training and demonstrates usage of age-specific customer service skills.

Benefits

• General environment: Works in a well-lighted, air-conditioned area, with moderate noise levels.
• May be exposed to high noise levels and bright lights.
• May be exposed to limited hazardous substances or body fluids, or infectious organisms.
• May be required to change from one task to another of different nature without loss of efficiency or composure.
• Periods of high stress and fluctuating workloads may occur.
• May be scheduled as needed including overtime.

Physical Requirements

• Have near normal vision - Clarity of vision (both near and far), ability to distinguish colors.
• Have good manual dexterity and eye-hand-foot coordination.

Physical Demands

• Standing - Frequently within shift (34-66%)
• Walking - Frequently within shift (34-66%)
• Sitting - Frequently within shift (34-66%)
• Climbing - Occasionally within shift (1-33%)
• Bending/Stooping - Frequently within shift (34-66%)
• Twist at waist - Frequently within shift (34-66%)
• Pushing/Pulling - Frequently within shift (34-66%)
• Lift/carry up to 20 lbs - Frequently within shift (34-66%)
• Lift/carry > 20 lbs with assistance - Occasionally within shift (1-33%)
• Reaching above shoulder - Frequently within shift (34-66%)