Job Description

UR Specialist- Care Management (Remote) at Phoebe Putney Health System summary:

This role involves performing utilization review duties, including obtaining certifications, authorizations, and communicating clinical information to insurance companies in support of patient care and hospital billing. The specialist liaises with third-party payers, care managers, social work staff, and physicians to coordinate care management and ensure compliance with state, federal, and contractual requirements. The position requires strong organizational skills, acute clinical judgment, and the ability to manage fluctuating workloads while maintaining high standards of communication and patient advocacy.

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 complext 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 managment functions and meeting patient needs. Will notifiy Care Managers of potential denials and communicate with patient physician and payer medical director for peer to peer discussions.

GENERAL REQUIREMENTS

• 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 (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.

WORKING CONDITIONS

• General environment: Works in a well-lighted, air-conditioned area, with moderate noise levels.
• May be exposed to high noise levels and bright lights.
• May be exposed to limited hazardous substances or body fluids, or infectious organisms.
• May be required to change from one task to another of different nature without loss of efficiency or composure.
• Periods of high stress and fluctuating workloads may occur.
• May be scheduled as needed including overtime.

EDUCATION REQUIREMENTS

• 2 year / Associate Degree in Nursing (Required)
• 4 year / Bachelor's Degree in Nursing (Preferred)

EXPERIENCE REQUIREMENTS

• 4 - 5 years Recent and relevant acute clinical care experience (Required)
• 1 - 2 years Utilization review experience in a hospital, managed care or physician office practice setting. (Required)

CERTIFICATIONS AND LICENSURES

• Required Certifications/Licensures: Registered Nurse (RN) with current Georgia license
• Preferred Certifications/Licensures: CCM or CPUR

GENERAL SKILLS

• Interpersonal Skills
• Customer Relations
• Mathematical
• Analytical
• Grammar / Spelling
• Read / Comprehend Written Instructions
• Follow Verbal Instructions
• Transcription
• Microsoft Office Suite
• General Clerical Skills
• Proficient computer typing skills, use of electronic health record and internet.
• Able to generate basic spreadsheets and word documents.
• Highly organized and detail oriented with ability to meet tight timeframes and time sensitive actions.
• Effective verbal and written communication skills

PHYSICAL REQUIREMENTS

• Have near normal vision - Clarity of vision (both near and far), ability to distinguish colors
• Have good - manual dexterity and eye-hand-foot coordination

PHYSICAL DEMANDS

• Standing - Frequently within shift (34-66%)
• Walking - Frequently within shift (34-66%)
• Sitting - Frequently within shift (34-66%)
• Climbing - Occasionally within shift (1-33%)
• Bending/Stooping - Frequently within shift (34-66%)
• Twist at waist - Frequently within shift (34-66%)
• Pushing/Pulling - Frequently within shift (34-66%)
• Lift/carry up to 20 lbs - Frequently within shift (34-66%)
• Lift/carry > 20 lbs with assistance - Occasionally within shift (1-33%)
• Reaching above shoulder - Frequently within shift (34-66%)

Phoebe Putney Health System employees are prohibited from working as Remote employees in the following states:

• California
• Colorado
• Connecticut
• Hawaii
• Maryland
• Massachusetts
• Michigan
• Nevada
• New Jersey
• New York
• Oregon
• Rhode Island
• Vermont
• Washington
• Washington D.C.

Keywords:

RN, Utilization Review, Care Management, Remote, Insurance Certification, Authorization, Patient Care, Clinical Communication, Hospital Billing, Medical Necessity

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