Utilization Review Team Lead (RN)

Children's Healthcare of Atlanta•Brookhaven, GA

6d•Remote

About The Position

Participates as a team leader to proactively support efforts that ensure effective and efficient utilization review services, clinical reviews, pre-certification, denial analysis, and other revenue functions. Maintains necessary documentation and communication with internal and external customers. Serves as resource for departmental employees when manager/supervisor is not available. 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.

Requirements

Two years of experience in a healthcare setting; pediatrics preferred
Six months of experience in hospital or insurance related utilization review
Graduation from an accredited school of nursing
Licensure as a Registered Nurse in the single State of Georgia or Multi-State through the Enhanced Nurse Licensure Compact
Must be able to successfully pass the Basic Windows Skill Assessment at 80% or higher rating within 30 days of employment

Nice To Haves

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

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.