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Work Shift

Work Day(s)

Shift Start Time

Children’s is one of the nation’s leading children’s hospitals. No matter the role, every member of our team is an essential part of our mission to make kids better today and healthier tomorrow. We’re committed to putting you first, and that commitment is at the heart of our company culture: People first. Children always. Find your next career opportunity and make a difference doing what you love at Children’s.

Experience

• Minimum of five years’ clinical experience in a hospital setting or other relevant experience

Preferred Qualifications

• Knowledge of Interqual or other clinical criteria
• Knowledge of both physician and hospital related managed care contracts

Certification Summary

• Board certified and licensed to practice medicine in the state of Georgia
• Current DEA registration
• Meets eligibility requirements for credentialing as part of the Children’s Healthcare of Atlanta Professional Staff

Education

• Graduate of an accredited, four-year medical school
• Graduate of an accredited, post-graduate residency program in Pediatrics

Knowledge, Skills and Abilities

• Demonstrated excellent written and oral communication skills
• Ability to develop strong working relationships with medical directors of managed care companies
• Working knowledge of regulations governing hospitals and medical staffs, managed care and quality management
• Excellent organizational and follow through skills
• Demonstrates the following skills in accomplishing job duties and responsibilities: personal organization and time management, human relations and teamwork, personal adaptability, personal motivation, listening

Job Responsibilities

• Serves as clinical resource for utilization management staff to clarify concerns related to medical necessity criteria for admission.
• Facilitates the secondary review process when clinical treatment or plans are in question.
• Serves as a liaison for the medical staff in reviewing and facilitating appropriate reimbursement for managed care patients.
• Provides physician education related to precertification, UR roles and responsibilities, and denial trends.
• Works with other Children’s and managed care leaders on special task forces to enhance Children’s managed care processes, procedures, and operations to better manage payor agreements (e.g., uses medical literature to support Children’s positions when we see trends in denials).
• Evaluates reports and information as necessary to ensure proper detail of reimbursement related to managed care contracts and the appeals process.
• Identifies trends and process improvements in the denial management process.
• Serves as co-chair of UM Committee and participates in other relevant meetings such as Medicaid steering committee and joint operations meetings.
• Provides medical leadership to case management to ensure safe, timely, and efficient discharges.
• Supports legal department regarding issues related to medical necessity denials and UM compliance.
• Meets with officials of DCH, GMF and others to support need for payment for a variety of issues.
• Participates in internal audits and helps Children’s UM and other leaders to maintain compliance with federal, state, and contractual requirements.

Children’s Healthcare of Atlanta is an equal opportunity employer committed to providing equal employment opportunities to all qualified applicants and employees without regard to race, color, sex, religion, national origin, citizenship, age, veteran status, disability or any other characteristic covered by applicable law.