Quality Utilization Reviewer I

Children's of Alabama; Birmingham (AL); On-site; USD 60,000 - 80,000; Full time

Job summary

Children's of Alabama in Birmingham is seeking an UR Reviewer 1 for Utilization Management at the Main Campus Lee Building. The role conducts inpatient admission, concurrent, and observation reviews for AL Medicaid and other payers, with potential advancement to Reviewer 2 after training and management approval.

Requirements include graduation from an accredited Nursing or Social Work program, AL RN or LPN licensure, and 2 years in hospital or related experience; knowledge of payer requirements

Qualifications

• Graduate of an accredited School of Nursing or Social Work.
• 2 years in hospital setting or related field (i.e., third-party payer).
• Current AL licensure as RN or LPN.
• Knowledge of third-party payer requirements in utilization review preferred.

Responsibilities

• Perform inpatient admission, concurrent, and observation reviews based on criteria for AL Medicaid and other payers.
• Work within Utilization Management at Main Campus Lee Building; participate in training for progression to Reviewer 2.

Skills

RN licensure

LPN licensure

Utilization review knowledge

Payer requirements

Education

Associate of Science in Nursing

Bachelor of Science in Nursing

Job description

In Utilization Management at Main Campus Lee Building

Work schedule will be Full-time on the Day Shift, Monday - Friday 8:00 am - 4:30 pm.

Summary

The UR Reviewer 1 is responsible for performing inpatient admission, concurrent, and observation reviews based on pre-established criteria exclusively for AL Medicaid and all commercial payers other than BCBS AL. Upon successful completion of training by UR Reviewer 2 and with the approval of the UR Manager & Department Director, UR Reviewer 1 with LPN/RN licensure may advance to Reviewer 2 (if position becomes available).

Other information

• Graduate of an accredited School of Nursing or Social Work

• 2 years in hospital setting or related field (i.e. third-party payer)
• Utilization review experience preferred

• Current AL licensure as RN or LPN

• Knowledge of third-party payer requirements in utilization review preferred

Credentials with Equivalent Qualifications

Essential:

• Registered Nurse AL Single State or any of the following equivalent qualifications below:
• Registered Nurse AL NLC Multi State
• Registered Nurse Non-AL NLC Multi State
• Licensed Practical Nurse AL Only
• Licensed Practical Nurse AL NLC Multi State
• Licensed Practical Nurse Non-AL NLC Multi State
• Licensed Independent Clinical Social Worker

Education with Equivalent Qualifications

Essential:

• Associate of Science Nursing in Nursing or Bachelors of Science or Arts in Nursing

Experience with Equivalent Qualifications

Essential:

• 2 Years Staff Level

Schedule: Monday - Friday 8:00 am - 4:30 pm, Day Shift, 8-Hour Shifts