Utilization Review Nurse

Public Consulting Group LLC (PCG) is a leading public sector solutions implementation and operations improvement firm that partners with health, education, and human services agencies to improve lives. Founded in 1986, PCG employs approximately 2,000 professionals throughout the U.S.—all committed to delivering solutions that change lives for the better. The firm is a member of a family of companies with experience in all 50 states, and clients in three Canadian provinces and Europe. PCG offers clients a multidisciplinary approach to meet challenges, pursue opportunities, and serve constituents across the public sector. To learn more, visit www.publicconsultinggroup.com.

PCG is currently seeking a Utilization Review Nurse. The Utilization nurse will also be responsible for utilizing a medical management software system on a day-to-day basis. The purpose of the Fund is to provide a funding source for future health care costs associated with birth‐related neurological injuries.

Performs prior authorization, concurrent and retrospective reviews Use clinical documentation and clinical review criteria to make determinations regarding qualifying health care costs Accurately records all review determinations and supporting documentation Contacts providers and members according to established timeframes Identifies and refers cases that do not meet established clinical or other criteria to the Case Management Supervisor Identifies and communicates quality issues to the Case Management Supervisor Communicates information to other team members Utilizes knowledge of community resources and the member’s benefit structure Interacts with providers, vendors, and facilities in a professional and respectful manner Recognizes quality of care issues and escalates the issues appropriately Understand and facilitate the Appeals and Grievances process Assists members with the coordination of services from various settings as appropriate Performs other duties as assigned