Utilization Review Nurse

Public Consulting Group • Charleston, WV • 1d ago

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

Supervisory Responsibility

None

Working Conditions

Office Setting

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.

LI

LI-LR1

LI-remote

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 the following reasonable range of compensation for this role below. In addition, PCG provides a range of benefits for this role, including medical and dental care benefits, 401k, PTO, parental leave, bereavement leave.

As required by applicable law, PCG provides the following reasonable range of compensation for this role: $78,500-$85,000. In addition, PCG provides a range of benefits for this role, including medical and dental care benefits, 401k, PTO, parental leave, bereavement leave.

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.

Public Consulting Group is an equal opportunity employer. All qualified applicants receive consideration for employment without regard to race, color, religion, gender, national origin, age, sexual orientation, gender identity, protected veteran status, or status as a qualified individual with a disability. VEVRAA Federal Contractor.

Similar Jobs

Oracle Health Lead Engagement Owner

Oracle • Charleston, WV • 3h ago

Hospital & Medical

Job Description PLEASE NOTE: Role requires the candidate to be a US Citizen, have the ability to gain Federal Security Clearance and be willing to travel 100% of the time. This Lead Engagement Owner role will be accounta...

3h ago

Go to Apply

Registered Nurse, RN

Genesis Healthcare • Marmet, WV • 1d ago

Hospital & Medical

Overview Full-Time Nightshift At Genesis Healthcare, we are dedicated to improving the lives we touch through the delivery of high-quality care and exceptional service. As a leading provider in the long-term care industr...

1d ago

Go to Apply

Clinical Quality Operations Manager - Remote

Merck • Charleston, WV • 1d ago

Hospital & Medical

Job Description In partnership with the Clinical Quality Operations Lead (CQOL and Head of CQO, the CQOM is accountable for the execution of operational quality activities within the assigned therapeutic area. This inclu...

1d ago

Go to Apply

[Remote] Senior Software Developer- Full Stack- Healthcare AI

Oracle • Charleston, WV • 3d ago

Hospital & Medical

Job Description Job Description : Are you ready to embark on a journey that will revolutionize healthcare and improve patient outcomes on a global scale? The Oracle Health division is leading the charge in healthcare inn...

3d ago

Go to Apply

Registered Nurse, RN

Genesis Healthcare • Hurricane, WV • 5d ago

Hospital & Medical

Overview At Genesis Healthcare, we are dedicated to improving the lives we touch through the delivery of high-quality care and exceptional service. As a leading provider in the long-term care industry, we believe in fost...

5d ago

Go to Apply

Pharmacy Operations Manager

Walgreens • Cross Lanes, WV • 5d ago

Hospital & Medical

Job Description: Where state and federal laws/regulations allow, accountable for performing day-to-day non-clinical pharmacy operations, administrative activities; Ensures efficient pharmacy workflow and a positive patie...

5d ago

Go to Apply

Registered Nurse, RN

Genesis Healthcare • Dunbar, WV • 1w ago

Hospital & Medical

1w ago

Go to Apply

Application Sales Representative - Casino & Hospitality (West Region)

Oracle • Charleston, WV • 1w ago

Hospital & Medical

Job Description Application Sales Representative - Casinos & Hospitality Oracle Hospitality & Leisure Location: West Region ( CO, NV, CA, AZ, WA, OR) About the Role We're looking for a driven Application Sales Re...

1w ago

Go to Apply

Dietary Aide

Healthcare Services Group, Inc. • Charleston, WV • 1w ago

Hospital & Medical

Overview Role: Dietary Aide Join Healthcare Services Group (HCSG) as a Dietary Aide, where you will prepare and serve meals for residents in a long-term care facility. At HCSG, we are passionate about positively impactin...

1w ago

Go to Apply

Utilization Management Nurse Consultant

CVS Health • Charleston, WV • 1w ago

Hospital & Medical

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions compan...

1w ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.