Quality Utilization Reviewer I

Children's of Alabama • Birmingham, AL

6d • Onsite

About The Position

The Quality Utilization Reviewer I works in Utilization Management at the Main Campus Lee Building. The role performs inpatient admission, concurrent, and observation reviews using pre-established criteria exclusively for Alabama Medicaid and commercial payers other than BCBS Alabama.

After successfully completing training by a UR Reviewer 2 and receiving approval from the UR Manager and Department Director, a UR Reviewer 1 with LPN or RN licensure may advance to Reviewer 2 if a position becomes available.

Requirements

• Graduate of an accredited School of Nursing or Social Work.
• Two years of experience in a hospital setting or related field, such as a third-party payer.
• Current Alabama licensure as an RN or LPN; listed equivalent qualifications include specified Alabama and multistate RN/LPN licenses and Licensed Independent Clinical Social Worker.
• Equivalent education qualifications listed include an Associate of Science in Nursing or a Bachelor of Science or Arts in Nursing.
• Equivalent experience qualification listed: two years at staff level.

Nice To Haves

• Utilization review experience is preferred.
• Knowledge of third-party payer requirements in utilization review is preferred.

Responsibilities

• Perform inpatient admission reviews based on pre-established criteria for Alabama Medicaid and commercial payers other than BCBS Alabama.
• Perform concurrent reviews based on pre-established criteria for Alabama Medicaid and commercial payers other than BCBS Alabama.
• Perform observation reviews based on pre-established criteria for Alabama Medicaid and commercial payers other than BCBS Alabama.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree