Job description
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.
Responsibilities
- 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
Requirements
- Required Skills: Possesses effective verbal/written communication skills, especially via phone, with the ability to interact with various levels of personnel.
Able to work in a fast-paced environment, demonstrate excellent problem solving, critical thinking, and organizational skills.
Performs multiple tasks efficiently and accurately, have exceptional attention to detail and perform consistent work product
Self-motivated, self-directed, team oriented, and responsible, with a positive attitude and a proactive style
Possesses the ability to operate in a highly variable work environment.
Presents a courteous and competent demeanor to our clients and teammates.
Excellent customer service skills
Strong computer skills
Ability to easily navigate through website research.
Qualifications: Graduated from an accredited School of Nursing, Associate Degree, Bachelor’s preferred
Minimum of 2 years of direct clinical nursing experience
Minimum of 2 years of experience with medical management activities in a managed care environment, Medicaid or hospital utilization management
RN required
Working Conditions: Remote
About Public Consulting Group
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.
