Utilization Review Representative

The Utilization Review Representative is responsible for utilization review of all inpatient and outpatient statuses. This individual is also responsible for the daily processing of internal and external authorization requests with payors for treatments, services, and supplies in collaboration with the RN Care Managers Inpatient and Outpatient. Will assist in the completion of the RN Care Manager's case load as assigned, promoting a positive approach to all activities related to data collection, insurance verification, financial counseling and customer service. This role ensures that the work processed is accurate and complete in all areas of responsibilities.

Responsibilities

Utilization review of all inpatient and outpatient statuses; Daily processing of internal and external authorization requests with payors for treatments, services, and supplies in collaboration with the RN Care Managers Inpatient and Outpatient; Assist in completing the RN Care Manager's caseload as assigned; Promote a positive approach to all activities related to data collection, insurance verification, financial counseling and customer service; Ensure the work processed is accurate and complete in all areas of responsibilities

Requirements

2 years of acute care or ambulatory care experience; Graduate of an accredited Licensed Vocational Nursing program; Licensed Vocational Nurse – CA (LVN); Basic Life Support (BLS); Ability to work effectively under pressure due to changing priorities, interruptions, high/low census, payor demands and discharge planning demands; Excellent interpersonal communication, including conflict resolution, problem solving and negotiation skills; Clinical knowledge of multiple age groups, medical illness, and treatment plans according to disease process, diagnosis, and anticipated LOS; Strong organizational and time management skills, including capacity to multi-task and prioritize; Ability to work independently and exercise sound judgment in interactions with physicians, payers, patients, and their families; Ability to communicate with third party payers to obtain authorization for the appropriate treatment setting for patients requiring medical, psych, and chemical dependency treatment; Must be proficient in required competencies upon completion of orientation and maintain annual departmental competency requirements; Ability to work collaboratively regardless of social, economic and cultural backgrounds; Computer knowledge including Microsoft Office (Excel, Word, Power Point, Access)

Nice to have

Certification in Utilization Review and/or Case Management; CPN; Knowledge of CCS/Medi-Cal regulations and requirements; Knowledge of third party payor requirements in order to optimize reimbursement; Ability to apply severity of illness/intensity of service pediatric criteria to information extracted from clinical documentation; Knowledge of third party payor methods; Bilingual; Over one (1) year of nursing experience in an acute care or ambulatory setting; One (1)+ years of pediatric nursing experience; Prior experience as Utilization Review nurse; Graduation with a Bachelors Degree in nursing from an accredited University; Ped Emerg Assess Recog & Stabil (PEARS); Comprehensive Crisis Management (CCM); Certified Pediatric Nurse (CPN)