UR Specialist, Care Command RN

Phoebe Putney Memorial Hospital; United States; Vor Ort; USD 70.000 - 90.000; Vollzeit

Zusammenfassung

Phoebe Putney Memorial Hospital in Albany, GA is seeking an RN UR Specialist to manage utilization review activities, certifications, and authorizations in Care Management. You will coordinate with insurance payers, inform CM staff of requirements, and support medical necessity justification and hospital billing.

This on-site role emphasizes collaboration with Care Managers and Social Work to optimize patient transitions.

Qualifikationen

• Associate's Degree in Nursing (Required).
• Bachelor's Degree in Nursing (Preferred).

Aufgaben

• Completes utilization review functions on assigned caseload and serves as a CM resource for payer updates.
• Notifies physician offices of required notification, precertification or authorizations as necessary.
• Communicates pertinent clinical information to insurance companies as needed.
• Notifies attending physicians of potential denials and coordinates peer-to-peer discussions.
• Documents UM reviews and outcomes in the electronic system with accurate data.
• Coordinates with Care Managers, Social Workers and CM staff to prevent denials and support patient transitions.

Ausbildung

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Jobbeschreibung

Job Number: 35406

Location: Phoebe Putney Memorial Hospital

Street Address: 417 W 3rd Ave

City, State: Albany, Georgia

Zip Code: 31701

Department: PPMH COMMAND CENTER

Shift: 7P7A Shift

Job Type: Full time

Posted Date: 2026-11-02

Job Description 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. This position will be on-site.

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 notify Care Managers of potential denials and communicate with patient physician and payer medical director for peer to peer discussions. This position will be on-site.

Education

• Associate's Degree in Nursing (Required)
• Bachelor's Degree in Nursing (Preferred)

Experience

• 3+ Recent and relevant acute clinical care experience (Required)
• 1+ Utilization review experience in a hospital, managed care or physician office practice setting (Required)

Certifications/Licensures

• Registered Nurse (RN) in the state of Georgia (Required)
• Certified Case Manager (Preferred)
• Certified Professional Utilization Review (Preferred)

Essential Functions

Utilization Review -RN:

• Completes utilization review functions on assigned caseload or area and serves as a resource for CM staff, physicians and other staff. Functions as liaison and resource regarding updates in payer requirements and hospital processes. Assures appropriate authorizations for patient level of care and works to avert potential payer denials.
• Notifies Physician offices of required notification, precertification or authorizations as necessary.
• Communicates pertinent clinical information to insurance companies as needed.
• Communicates all relevant information to the appropriate Care Management staff. Notifies attending physicians of potential insurance company denials; may take verbal orders for change in patient status.
• Notifies attending physicians of potential insurance company denials and coordinated peer to peer physician case review.
• Participates in data collection as directed by the Care Management Director. Ensures accuracy, timeliness and integrity of data. Identifies any performance improvement opportunities, proposes resolutions, and records on appropriate forms.
• Coordinates with the unit Care Managers, Social Workers and CM staff to assure payer decisions are known and actions taken as needed to prevent denials or patient liability.
• Works closely with Patient Accounts and Revenue Cycle areas to address payer issues and reconciliations of accounts as needed.

UR Documentation & Electronic System:

• Documents and records review activity, follow up and outcomes in the appropriate electronic system as required; assures documented/recorded information and data are timely and inclusive of pertinent facts.
• Clearly and accurately documents UM related reviews, referrals, activities related to utilization review, approvals, denials, avoidable delays and outcomes.
• Ensures that documentation is tailored to expected readers / users.
• Uses correct terminology in accordance with hospital standards and conforms to required style and format.
• Applies medical staff approved clinical criteria to reviews and in accordance with payer standards and requirements.
• Utilizes applicable payer portals to inp