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Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

Primary responsibility of the Utilization Review Nurse is to evaluate and screen all admissions using screening guidelines to ensure patients are in the appropriate status and level of care based on Physician documentation. The Utilization Review Nurse will monitor the patient's progression in their plan of care and perform continue stay reviews to ensure patients are meeting medical necessity and remain in the appropriate level of care. Work collaboratively with the Physician, unit Case Manager and other members of the healthcare team to ensure appropriate plan of care, along with the appropriateness of services being rendered. Will be responsible for securing authorization and days approved with the payor by submitting clinical information justifying the need for admission and/or continued stay. 
 

Minimum Job Qualifications

• Licensure or other certifications: Current RN Licensure in the State of Georgia is required.

• Educational Requirements:

• Minimum Experience: Three (3) - five (5) years of experience as a Registered Nurse.  preferred.

• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications: CCM or ACM certification.

• Preferred Educational Requirements: Experience in Utilization Review, applying screening guidelines (InterQual or MCG) or other related Case Management experience (i.e Insurance Case Management, Workers Compensation, Home Healthcare).

• Preferred Experience:

• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Demonstrates aptitude and critical thinking skills in critical care, cardiac or med/surgical nursing

• Working knowledge of State and Federal regulations, medical necessity criteria and utilization management is required

• Must demonstrate excellent observation skills, analytical thinking, problem solving abilities, and excellent written and verbal communication

• Proficient computer skills to include, but not limited to, Microsoft Word, Excel, Electronic Medical Record, etc

• Knowledgeable of financial/reimbursement criteria as it relates to all payors

• Demonstrates interpersonal skills including professionalism, a team player, pleasing personality and positive approach to the position. The position requires the ability to be self directed
   

Essential Tasks and Responsibilities

• Perform admission, concurrent and retrospective reviews as required utilizing screening guidelines (InterQual) based on Physician documentation to ensure patient is in the right status and level of care. 

• Utilize working DRG and work collaboratively with the Physician, nursing staff and unit Clinical Case Manager to ensure patient's are meeting the expected length of stay and to assure a timely discharge and appropriate transition to the next level of care.  

• Communicate and coordinate with unit Clinical Case Manager on a daily, consistent basis to ensure patient's are in the right status and level of care; Facilitate changes by communicating with Physicians, mid-levels or nursing staff as needed. 

• Obtain precertification/recertification on assigned cases and documents authorization number, along with days approved, in the appropriate systems. Facilitates and coordinates peer to peer reviews on appropriate cases in an effort to avoid denial of services; documents outcomes as appropriate. 

• Track appropriate delay days; request second level reviews for appropriate patients not meeting per department standard work.

• Work assigned queues, including, but not limited to the following: Status Orders, Level of Care, Medical Necessity, Auth/Cert.

• Adheres to all regulatory and DNV requirements; Knowledgeable of third party payers (PPO/HMO's) to facilitate appropriate outcomes and ensure coverage of services rendered. 

• Provide coaching and education to physicians as needed regarding effective clinical documentation.

Physical Demands

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 20 lbs, % of time

• Vision: Moderate, Constantly 66-100% of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Occasionally 0-30%

• Pushing/Pulling: Occasionally 0-30%

• Intensity of Work: Frequently 31-65%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals. 

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.