UR Specialist, Care Command RN

Phoebe Putney Health System•Albany, GA

4d•Onsite

About The Position

The RN UR Specialist performs utilization review activities within Care Management, including insurance company notifications and obtaining certifications and authorizations. The role communicates clinical information and updates to insurers as required by contracts and regulations to support medical-necessity determinations, hospital billing, and payment for care and services. The specialist liaises with third-party payers on utilization review requirements, authorizations, and denials; assists with complex authorization needs that affect patient transitions; and coordinates with Care Managers and Social Work staff. The position also notifies Care Managers of potential denials and coordinates with physicians and payer medical directors for peer-to-peer discussions. This position is on-site. The specialist completes utilization reviews for an assigned caseload or area, serves as a resource on payer requirements and hospital processes, supports appropriate authorizations for patient level of care, and works to avert potential denials. The role documents reviews and outcomes in electronic systems, applies approved clinical criteria, uses payer portals, and communicates changes in payer requirements. It also collaborates with Care Management, Social Work, Patient Accounts, and Revenue Cycle staff; participates in data collection and performance improvement; and contributes to staff education, teamwork, committees, and projects.

Requirements

Associate's Degree in Nursing (required).
At least 3 years of recent and relevant acute clinical care experience (required).
At least 1 year of utilization review experience in a hospital, managed care, or physician office practice setting (required).
Registered Nurse (RN) licensure in the state of Georgia (required).

Nice To Haves

Bachelor's Degree in Nursing (preferred).
Certified Case Manager (preferred).
Certified Professional Utilization Review (preferred).

Responsibilities

Complete utilization review functions for an assigned caseload or area and serve as a resource for Care Management staff, physicians, and other staff.
Provide liaison and resource support regarding updates to payer requirements and hospital processes.
Ensure appropriate authorizations for patient level of care and work to avert potential payer denials.
Notify physician offices of required notifications, precertifications, or authorizations.
Communicate pertinent clinical information to insurance companies and relevant information to appropriate Care Management staff.
Notify attending physicians of potential insurance company denials, take verbal orders for changes in patient status when applicable, and coordinate peer-to-peer physician case reviews.
Participate in data collection as directed by the Care Management Director and ensure data accuracy, timeliness, and integrity.
Identify performance-improvement opportunities, propose resolutions, and record them on appropriate forms.
Coordinate with Care Managers, Social Workers, and Care Management staff to ensure payer decisions are known and actions are taken to prevent denials or patient liability.
Work with Patient Accounts and Revenue Cycle staff to address payer issues and account reconciliations as needed.
Document review activity, follow-up, and outcomes accurately and promptly in the appropriate electronic system, including reviews, referrals, approvals, denials, avoidable delays, and outcomes.
Apply medical-staff-approved clinical criteria in accordance with payer standards and requirements.
Use payer portals to enter clinical information and secure notifications and approvals.
Research updated payer manuals, bulletins, and requirements and communicate changes within Care Management, to the Director, and to the Chief Utilization Officer.
Educate staff, physicians, and patients about the UR Specialist role and changing payer trends and requirements.
Participate in teamwork, committees, workplace projects, professional organizations, or research in utilization management, and incorporate evidence-based knowledge into practice.
Follow hospital and departmental attendance, punctuality, policies, procedures, and core values; complete required duties, education, meetings, in-services, and competency evaluations.
Maintain current knowledge in areas of responsibility, including specialty certification requirements.
Demonstrate competency in providing care based on patient age, sex, weight, and demonstrated needs; for non-clinical areas, demonstrate age-specific customer-service skills.
Wear protective clothing and equipment as appropriate.