Utilization Review RN – Pediatric Hospital

Amergis Healthcare is seeking an experienced Registered Nurse and self-motivated individual to provide data collection and related activities for Quality Improvement (QI) and Utilization Review as well as completion of financial documents needed for level of care, billing, and reimbursement processes. For this role, the nurse will be adding Admissions and Insurance Authorizations. MUST have experience with Utilization Review, Authorizations and Admissions. 

Position Details:

• Location: Canton, MA
• Setting: Pediatric Hospital
• Schedule: Mon-Fri 8a-4p o r9a-5p
• Compensation: $75/hr local & $3,600 travel

Duties and Responsibilities (these duties are a general summary and not all inclusive):

• Collects and compiles data on the joint Commission’s prescriptive measures and others as appropriate in a timely manner.
• Assembles and collates data on physician-related indicators for use in the Medical
• Reviews and levels pre-admission abstracts when requested using established and approved criteria for utilization review.
• Compiles records and monitors information on a weekly basis when the patient is at an acute Level of Care (LOC) for changes in status.
• Reviews all patients for hospital stay medical necessity on an ongoing basis.
• Evaluates managed care patients as requested by insurer.
• Collaborates with the Billing team to complete and manage all financial documents needed for level of care, billing, and reimbursement.
• Provides support and coordination of all DME requests.  This collaboration is primarily with Case Management, PT, OT, SLP, and Rehab Engineering.
• Creates updates, maintains, and signs off on UR-related policy and procedures at least every 3 years.
• Provides staff support for Performance Improvement, root cause analysis, and failure mode effects analysis teams.
• Oversees training and educational needs for staff as appropriate.

Required Qualifications:

• Knowledge of the principles and practices of nursing.
• Capacity to integrate and interpret statistical data.
• Ability to gather information through observing and questioning individuals and by examining records and documents.
• Ability to work cooperatively and effectively with a multidisciplinary team.
• Talent for communicating effectively verbally and in writing.

Preferred Qualifications:

• Thorough knowledge of Joint Commission Standards, particularly those involving quality improvement.
• Current and up-to-date knowledge of changes to existing laws, standards, and regulations, and the ability to explain and interpret same to facility wide personnel.
•  Demonstrated understanding of external agency interface with Utilization Review, Case Management, Patient Safety and Quality Improvement.
•  High degree of organizational skills and strong written and oral communication skills, including methods of general report writing.Proficient in Microsoft Office applications including Excel, Word, Outlook, PowerPoint, and

If you have any questions or would like to learn more about this opportunity, please don’t hesitate to reach out. We look forward to connecting with you!

Adam Batchelor | Amergis Healthcare Services
Recruiter | Government Services
781-657-1826 | adbatche@amergis.com