Utilization Review Team Lead (RN)
Children's Healthcare of AtlantaNote: 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
VariableWork Day(s)
Saturday, Sunday, VariableShift Start Time
8:00 AMShift End Time
Worker Sub-Type
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
This role will focus on account status changes, reviewing denials and serving as resource for Clinical Review Nurses (UR). The schedule is (4) 10-hour days with 2 of those days being Saturday and Sunday. There is opportunity to work remotely.
Experience
- Two years of experience in a healthcare setting; pediatrics preferred
- Six months of experience in hospital or insurance related utilization review
Preferred Qualifications
- Bachelor of Science in Nursing
- Previous experience with InterQual and/or MCG programs
- Previous management or leadership experience
- Strong clinical skills; PICU or NICU very helpful
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
- Must be able to successfully pass the Basic Windows Skill Assessment at 80% or higher rating within 30 days of employment
Job Responsibilities
- Coordinates and performs activities related to determination of eligibility, precertification, and hospital stay approvals for all unplanned admissions as required by payor.
- Functions in place of staff as needed.
- Acts as resource for employees to handle/resolve difficult issues or answer questions.
- Acts as supervisor upon absence of supervisor.
- Maintains effective communication strategies so that collaboration and teamwork are enhanced throughout department and Children’s Healthcare of Atlanta.
- Serves as liaison between utilization review nurses and payors.
- Researches authorization requests from physician offices.
- Coordinates and performs activities related to status changes timely and consistently.
- Participates actively in secondary review process and provides feedback to staff where indicated.
- Escalates trends to Utilization Review supervisor and clinical educator for quality assurance purposes.
- Demonstrates competency in utilization review process with successful completion and passing of McKesson Interrater Reliability for both pediatric and adult criteria.
- Attends meetings with and communicates utilization review initiatives to outside departments, including Managed Care, Patient Accounting, Medical Staff, and Registration.
- Supports and participates in continuous assessment and improvement of patient care.
- Participates in Utilization Management committee activities.
- Provides reporting data to analyze performance of department, especially as relates to correct patient status.
- Assists supervisor and/or manager with development of staff by being available to teammates, acting as a resource to help complete complicated/complex tasks, providing on the job training to team, and seeking out opportunities to become actively involved in staff workflow and development.
- Provides supervisor and/or manager feedback on staff performance, educational needs, and workflow status.
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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