UR Specialist- Care Management (Remote)

Phoebe Putney Health System; Georgia (VT); Remote; USD 65,000 - 80,000; Full time

Job summary

A leading healthcare provider is seeking an RN UR Specialist to manage insurance notifications and authorizations for patient care. The role involves coordinating with Care Managers and third-party payers to ensure timely communication and support for medical necessity. Candidates should possess a nursing degree and have relevant clinical experience. Strong communication and analytical skills are essential for success in this position.

Qualifications

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

Responsibilities

• Perform activities related to insurance notifications and authorizations.
• Communicate clinical information to insurance companies.
• Liaise with third-party payers regarding UR requirements.

Skills

Interpersonal skills

Analytical skills

Communication skills

Education

Associate Degree in Nursing

Bachelor’s Degree in Nursing

Tools

Microsoft Office

Electronic health records

Job description

Job Summary

The primary responsibilities of the RN UR Specialist include performing activities related to insurance company notifications, obtaining certifications and authorizations for Utilization Review duties in Care Management. The role involves timely communication of clinical information and updates to insurance companies, supporting medical necessity justification, hospital billing, and payment for patient care and services. The RN UR Specialist liaises with third-party payers regarding UR requirements, authorization or denial matters, and assists with complex authorization needs impacting patient transition planning. Proactive communication with Care Managers and Social Work staff fosters coordination for key care management functions and meeting patient needs. The specialist also notifies Care Managers of potential denials and communicates with patient physicians and payer medical directors for peer-to-peer discussions.

General Requirements

• Adheres to hospital and departmental attendance and punctuality guidelines.
• Performs all responsibilities aligned with the organization’s core values, mission, and vision.
• Completes all job functions as per departmental policies and procedures.
• Maintains current knowledge through self-education and ongoing training.
• Attends staff meetings, mandatory in-services, and completes competency evaluations on time.
• Provides competent care to patients based on age, sex, weight, and needs; demonstrates customer service skills in non-clinical areas.

Working Conditions

• Works in a well-lighted, air-conditioned environment with moderate noise levels.
• May be exposed to high noise levels, bright lights, hazardous substances, infectious organisms, and body fluids.
• May need to switch tasks rapidly and handle high stress and fluctuating workloads.
• May be scheduled for overtime as needed.

Education Requirements

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

Experience Requirements

• 4-5 years recent acute clinical care experience (Required)
• 1-2 years utilization review experience in a hospital, managed care, or physician office setting (Required)

Certifications and Licensures

• Current Georgia RN license (Required)
• CCM or CPUR certifications (Preferred)

General Skills

• Interpersonal and customer relations skills
• Mathematical and analytical skills
• Excellent grammar and spelling
• Ability to read and follow written and verbal instructions
• Proficiency in Microsoft Office and electronic health records
• Organized, detail-oriented, and capable of meeting tight deadlines
• Effective verbal and written communication skills

Physical Requirements

• Near normal vision, manual dexterity, and eye-hand-foot coordination

Physical Demands

• Frequent standing, walking, sitting, bending, twisting, pushing, pulling, reaching, and lifting up to 20 lbs
• Occasional lifting over 20 lbs with assistance

Note

Phoebe Putney Health System employees are prohibited from working remotely in the following states: California, Colorado, Connecticut, Hawaii, Maryland, Massachusetts, Michigan, Nevada, New Jersey, New York, Oregon, Rhode Island, Vermont, Washington, and Washington D.C.