UR Specialist- Care Management (Remote)

Phoebe Putney Health System; Georgia (VT); Remote; USD 70,000 - 85,000; Full time

Job summary

Join a leading health system as a UR Specialist in Care Management. This remote role involves managing insurance notifications and authorizations, ensuring compliance with regulations, and coordinating with care teams to meet patient needs. Ideal candidates will have a nursing degree and relevant experience in clinical care and utilization review.

Qualifications

• 4-5 years recent and relevant acute clinical care experience required.
• 1-2 years Utilization review experience in a hospital or managed care setting required.

Responsibilities

• Perform activities related to insurance company notifications and authorizations.
• Communicate clinical information to insurance companies for medical necessity justification.

Skills

Interpersonal Skills

Customer Relations

Mathematical and Analytical skills

Effective verbal and written communication skills

Education

2-year / Associate Degree in Nursing

4-year / Bachelor's Degree in Nursing

Tools

Microsoft Office Suite

Job description

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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 complex 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 management functions and meeting patient needs. Will notify Care Managers of potential denials and communicate with patient physicians and payer medical directors 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, 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

• 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, 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 Licenses

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

General Skills

• Interpersonal Skills
• Customer Relations
• Mathematical and Analytical skills
• 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 (34-66%)
• Walking frequently (34-66%)
• Sitting frequently (34-66%)
• Climbing occasionally (1-33%)
• Bending/Stooping frequently (34-66%)
• Twist at waist frequently (34-66%)
• Pushing/Pulling frequently (34-66%)
• Lift/carry up to 20 lbs frequently (34-66%)
• Lift/carry > 20 lbs with assistance occasionally (1-33%)
• Reaching above shoulder frequently (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.

Seniority level

• Mid-Senior level

Employment type

• Contract

Job function

• Health Care Provider

Industries

• Hospitals and Health Care

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