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JOB SUMMARY

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. He/she will liaison with third party payers regarding UR requirements, authorization or denial matters, and will assist with complex authorization needs impacting patient transition planning. Proactive communication with Care Manager and Social Work staff will foster coordination and a team approach for key care management functions and meeting patient needs. Will notify Care Managers of potential denials and communicate with patient physician and payer medical director for peer to peer discussions. This position will be on-site.

EDUCATION

• Associate's Degree in Nursing (Required)
• Bachelor's Degree in Nursing (Preferred)

EXPERIENCE

• 3 Recent and relevant acute clinical care experience (Required)
• 1 Utilization review experience in a hospital, managed care or physician office practice setting (Required)

CERTIFICATIONS/LICENSURES

• Registered Nurse (RN) in the state of Georgia (Required)
• Certified Case Manager (Preferred)
• Certified Professional Utilization Review (Preferred)

ESSENTIAL FUNCTIONS

UTILIZATION REVIEW - RN:

• Completes utilization review functions on assigned caseload or area and serves as a resource for CM staff, physicians and other staff.
• Functions as liaison and resource regarding updates in payer requirements and hospital processes.
• Assures appropriate authorizations for patient level of care and works to avert potential payer denials.
• Notifies Physician offices of required notification, precertification or authorizations as necessary.
• Communicates pertinent clinical information to insurance companies as needed.
• Communicates all relevant information to the appropriate Care Management staff.
• Notifies attending physicians of potential insurance company denials; may take verbal orders for change in patient status.
• Notifies attending physicians of potential insurance company denials and coordinated peer to peer physician case review.
• Participates in data collection as directed by the Care Management Director.
• Ensures accuracy, timeliness and integrity of data.
• Identifies any performance improvement opportunities, proposes resolutions, and records on appropriate forms.
• Coordinates with the unit Care Managers, Social Workers and CM staff to assure payer decisions are known and actions taken as needed to prevent denials or patient liability.
• Works closely with Patient Accounts and Revenue Cycle areas to address payer issues and reconciliations of accounts as needed.

UR DOCUMENTATION & ELECTRONIC SYSTEM:

• Documents and records review activity, follow up and outcomes in the appropriate electronic system as required; assures documented/recorded information and data are timely and inclusive of pertinent facts.
• Clearly and accurately documents UM related reviews, referrals, activities related to utilization review, approvals, denials, avoidable delays and outcomes.
• Ensures that documentation is tailored to expected readers/users.
• Uses correct terminology in accordance with hospital standards and conforms to required style and format.
• Applies medical staff approved clinical criteria to reviews and in accordance with payer standards and requirements.
• Utilizes applicable payer portals to input clinical information, secure notifications and approvals.
• Researches sites for updated manuals, bulletins and requirements and communicates changes within Care Management department, to Director and Chief Utilization Officer.

CM / UM LEADERSHIP:

• Engages in teamwork as a team player and a team leader.
• Educates staff, physicians and patients about the role of UR Specialist and changing payer trends and requirements.
• Serves on committees or participates in projects at work with opportunities for shared decision making and being a change agent.
• Promotes professionalism of role through participation in professional organizations and/or research in utilization management.
• Incorporates evidence based knowledge in practice.

ADDITIONAL DUTIES

• 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 to include any specialty certification requirements (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.
• Wears protective clothing and equipment as appropriate.

Being aware of others' reactions and understanding why they react as they do.

Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.

Adjusting actions in relation to others' actions.

Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.

Actively looking for ways to help people.

Talking to others to convey information effectively.

Considering the relative costs and benefits of potential actions to choose the most appropriate one.

Understanding written sentences and paragraphs in work-related documents.

Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action.