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Public Consulting Group - PCG logo
Public Consulting Group - PCG

Public Consulting Group - PCG is a Boston, Massachusetts-based firm that specializes in improving lives by providing technology and consulting services in the s

Utilization Review Nurse

Location

United States

Posted

102 days ago

Salary

$76K - $85K / year

Seniority

Mid Level

No structured requirement data.

Job Description

Utilization Review Nurse

Public Consulting Group - PCG

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. 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

Job Requirements

  • 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
  • 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

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