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Role 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.

• Performs prior authorization, concurrent and retrospective reviews
• Uses 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
• Understands and facilitates the Appeals and Grievances process
• Assists members with the coordination of services from various settings as appropriate
• Performs other duties as assigned

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

Requirements

• 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, has exceptional attention to detail and performs 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 clients and teammates
• Excellent customer service skills
• Strong computer skills
• Ability to easily navigate through website research

Benefits

• Compensation range: $76,000 - $85,000
• Medical and dental care benefits
• 401k
• PTO
• Parental leave
• Bereavement leave