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.

Duties and 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

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

The above is intended to describe the general contents and requirements of work being performed by people assigned to this classification. It is not intended to be construed as an exhaustive statement of all duties, responsibilities or skills of personnel so classified.

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Compensation:

Compensation for roles at Public Consulting Group varies depending on a wide array of factors including, but not limited to, the specific office location, role, skill set, and level of experience.  As required by applicable law, PCG provides a reasonable range of compensation for this role. In addition, PCG provides a range of benefits for this role, including medical and dental care benefits, 401k, PTO, parental leave, bereavement leave.

Range: $76,000 - $85,000

PCG does not sponsor newly hired foreign national workers for work authorization, including H-1B sponsorship.

EEO Statement:

Public Consulting Group is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PCG, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PCG will not tolerate discrimination or harassment based on any of these characteristics. PCG believes in health, equality, and prosperity for everyone so we can succeed in changing the ways the public sector, including health, education, technology and human services industries, work.