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Clinical Review Nurse, PRN

Work Schedule/Days:  Day / Variable
Employment Type:  PRN
Location:  Office Park (1644) 
Requisition #:  40241

 

JOB SUMMARY

Participates as a member of a multidisciplinary team in completing pre-screening assessments of prospective patients. Ensures completion of appropriate clinical review of all applicable patients as stated in system utilization management plan. Oversees Clinical Review Specialist as indicated.  Maintains necessary documentation and communication with internal and external customers.

 

EDUCATION
  • Graduation from an accredited school of nursing 

CERTIFICATION SUMMARY
  • Licensure as a Registered Nurse in the single State of Georgia or Multi-State through the Enhanced Nurse Licensure Compact

EXPERIENCE*
  • 3 years of experience in a healthcare setting
PREFERRED QUALIFICATIONS*
  • Bachelor of Science in Nursing
  • Experience in pediatrics
  • 2 years of experience in hospital or insurance related utilization review
KNOWLEDGE SKILLS & ABILITIES*
  • Working knowledge of financial aspects of third-party payors and reimbursement
  • Effective decision-making/problem-solving skills
  • Demonstration of creativity in problem-solving
  • Must possess above-average computer skills
  • Must be able to successfully pass the Basic Windows Skill Assessment at 80% or higher rating within 30 days of employment
JOB RESPONSIBILITIES*
  1. Provides clinical information to insurance companies as needed for completion of pre-certification process as noted in Children's Healthcare of Atlanta utilization management plan.
  2. Evaluates all patients, including critical care, for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria, and third-party information within 24 hours or next business day.
  3. Initiates and facilitates physician communications relative to utilization review process when indicated without prompting and follows up to ensure completion, including peer-to-peer reviews, securing admission orders, and reporting quality issues.
  4. Reviews concurrently all inpatients, including critical care, every three days or sooner if payor requests, including information regarding patient's medical condition, intensity of services being utilized, treatment plan, and established review criteria.
  5. Ensures all pertinent information is documented into various systems for utilization review process.
  6. Gathers and reviews relevant medical information and documents utilization review process outcome based on system accepted utilization criteria on the accepted current review forms and in computer systems.
  7. Supports organizational efforts to ensure accurate capture of admission status and level of care using Epic and escalating cases for status change where necessary.  
  8. Refers denied cases to appropriate personnel and provides assistance and/or clinical support to aid in appeal process.
  9. Serves as resource to Case Management for facilitation of patients moving to appropriate level of care and notifying when patients no longer meet medical necessity to aid in discharge planning.
  10. Meets productivity (10-12 reviews/day) and quality assurance (95%) standards and demonstrates utilization review proficiency with the successful completion and passing of McKesson Interrater Reliability testing.
  11. Attends all required onsite, telephonic, and mandatory department meetings.
  12. Participates in department activities to help promote utilization review process, aids in denial prevention, and serves as resource to peers and team members.
SYSTEM RESPONSIBILITIES*

Safety: Practices proper safety techniques in accordance with hospital and departmental policies and procedures. Responsible for the reporting of employee/patient/visitor injuries or accidents, or other safety issues to the supervisor and in the occurrence notification system.

 

Compliance: Monitors and ensures compliance with all regulatory requirements, organizational standards, and policies and procedures related to area of responsibility. Identifies potential risk areas within area of responsibility and supports problem resolution process. Maintains records of compliance activities and reports compliance activities to the Compliance Office.

 

The above statements are intended to describe the general nature and level of work performed by people assigned to this classification.  They are not intended to be an exhaustive list of all job duties performed by the personnel so classified.

PHYSICAL DEMANDS*
Ability to lift up to 40 lbs independently and greater than 40 lbs with assistance
Bending/Stooping - Occasionally (activity or condition exists up to 1/3 of time)
Climbing - Occasionally (activity or condition exists up to 1/3 of time)
Hearing/Speaking - Effective communication with employees, supervisors/managers and staff. Effective communications with patients and visitors, as required.
Lifting - Occasionally (activity or condition exists up to 1/3 of time)
Pushing/Pulling - Occasionally (activity or condition exists up to 1/3 of time)
Sitting - Constantly (activity or condition exists 2/3 or more of time)
Standing - Occasionally (activity or condition exists up to 1/3 of time)
Walking - Occasionally (activity or condition exists up to 1/3 of time)
WORKING CONDITIONS*
No potential for exposure to blood and body fluids

 

About Us:

Children’s Healthcare of Atlanta has been 100 percent committed to kids for more than 100 years. A not-for-profit organization, Children’s is dedicated to making kids better today and healthier tomorrow.

With 3 hospitals, 27 neighborhood locations and a total of 638 beds, Children’s is the largest healthcare provider for children in Georgia and one of the largest pediatric clinical care providers in the country. Children’s offers access to more than 70 pediatric specialties and programs and is ranked among the top children’s hospitals in the country by U.S. News & World Report.

Children’s has been ranked on Fortune magazine’s list of “100 Best Companies to Work For” for fourteen consecutive years and named one of the “100 Best Companies” by Working Mother magazine.  We offer a comprehensive compensation and benefit package that supports our mission, vision and values.  We are proud to offer an array of programs and services to our employees that have distinguished us as a best place to work in the country.  Connect to our mission of making kids better today and healthier tomorrow. 

Have questions about the recruitment process?  Check out What to Expect.

Address:  1644 Tullie Circle, Atlanta, GA  30329
Function:  Nursing - Nursing-Non Bedside


Nearest Major Market: Atlanta

Job Segment: Clinic, Nursing, Medical, EMR, Registered Nurse, Healthcare