Utilization​/Clinical Review RN -PRN

Job Overview

This PRN nursing position requires (6) 8-hour days per month, with one day on a weekend and participation in required holidays. Training and orientation include 3 days/week (8-hour days) for 8-10 weeks and onsite orientation for 3-4 days during the first week. The role is remote but requires regular onsite meetings and mandatory training at the Support Center in Atlanta, GA.

• 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.
• Provides clinical information to insurance companies for 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 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 payer 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 escalates 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.

Experience:

3 years of experience in a healthcare setting; pediatrics preferred.

Preferred Qualifications:

Bachelor of Science in Nursing;
Previous experience with MCG and/or Inter Qual systems; 2 years of experience in hospital or insurance related utilization review 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.

• 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.

Primary Location Address: 1575 Northeast Expy NE, Atlanta, GA

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.