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. This role performs inpatient admission, concurrent, and observation reviews using pre-established criteria exclusively for AL Medicaid and commercial payers other than BCBS AL. After successfully completing training by a UR Reviewer 2 and receiving approval from the UR Manager and Department Director, a reviewer 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, or one of the listed equivalent qualifications: RN Alabama single-state or NLC multistate, RN non-Alabama NLC multistate, LPN Alabama-only or NLC multistate, LPN non-Alabama NLC multistate, or Licensed Independent Clinical Social Worker.
• Equivalent education qualifications listed: Associate of Science in Nursing, or Bachelor of Science or Arts in Nursing.
• Equivalent experience qualification listed: two years at staff level.

Nice To Haves

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

Responsibilities

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

What This Job Offers

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