UR Specialist, Care Command RN

Phoebe Putney Memorial Hospital, Inc.; United States; On-site; USD 65,000 - 90,000; Full time

Job summary

Phoebe Putney Memorial Hospital, Inc. in Albany, GA is hiring an RN Utilization Review Specialist to perform UR notifications, obtain certifications, and coordinate with third-party payers.

The role involves ensuring medical necessity, coordinating denials prevention, and supporting care management with timely information. The position emphasizes on-site work, collaboration with Care Management, and documentation in electronic systems to meet payer requirements and improve patient transition

Qualifications

• Associate's Degree in Nursing is required.
• Bachelor's Degree in Nursing is preferred.
• 3+ recent and relevant acute clinical care experience is required.
• 1+ utilization review experience in a hospital, managed care or physician office setting is required.
• Registered Nurse (RN) in the state of Georgia is required.
• Certified Case Manager is preferred.
• Certified Professional Utilization Review is preferred.

Responsibilities

• Completes utilization review functions on assigned caseload and serves as a resource for CM staff, physicians and other staff.
• Documents and records review activity and uses payer portals to input clinical information, notifications and approvals.
• Engages in teamwork as a team leader and educates staff, physicians and patients about UR roles and payer trends.
• Performs other duties as required and completes all job functions per departmental policies.

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Job description

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.

Description:

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. 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 input clinical information, secure notifications and approvals. Researches sites for updated manuals, bulletins and requirements and communicates changes within Care Management department, to Director and Chief Utilization Officer.

CM / UM LEADERSHIP:

Engages in teamwork as a team player and a team leader. Educates staff, physicians and patients about the role of UR Specialist and changing payer trends and requirements. Serves on committees or participates in projects at work with opportunities for shared decision making and being a change agent. Promotes professionalism of role through participation in professional organizations and/or research in utilization management. Incorporates evidence based knowledge in practice.

ADDITIONAL DUTIES

• 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 to include any specialty certification requirements (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.
• Wears protective clothing and equipment as appropriate.

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Phoebe Putney Health System is southwest Georgia’s preferred career choice for professionals who want to improve the community’s health by joining a respected, cutting-edge team. We offer you the opportunity to collaborate with the best colleagues in a friendly, close-knit setting that feels like family. Your career at Phoebe will allow you to apply learned skills, explore new paths and advance into greater opportunities. There's more for you at Phoebe. Phoebe is simply the best, most advanced healthcare provider in the region. If you want to work in the medical field, we are the preferred choice, with the best technology, the most specialists and the area’s top talent. If you are searching for a non-clinical career that allows you to serve the community and grow, you’ll also find us ideal. We’re one of the area’s premier employers, offering a close-knit culture, outstanding benefits and many ways to develop your career.