Utilization Review Specialist / RN
Utilization Review Specialist / RN
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Job Description
Overview
Be inspired. Be rewarded. Belong. At Emory Healthcare.
At Emory Healthcare we fuel your professional journey with better benefits valuable resources ongoing mentorship and leadership programs for all types of jobs and a supportive environment that enables you to reach new heights in your career and be what you want to be. We provide:
- Comprehensive health benefits that start day 1
- Student Loan Repayment Assistance & Reimbursement Programs
- Family-focused benefits
- Wellness incentives
- Ongoing mentorship development and leadership programs
- And more
Description
The Utilization Review (UR) Specialist is a Registered Nurse responsible for conducting thorough medical necessity reviews to assist with determining appropriate patient class designation.
- The UR Specialist will perform timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with the UR Department workflows/processes clinical nursing judgement and when necessary discussions with the provider team and/or Medical Director of UR.
Primary duties and responsibilities:
Operational Support:
- Conducts thorough medical necessity reviews to assist with determining appropriate patient class designation.
- Performs timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with the UR Department workflows/processes clinical nursing judgement and when necessary discussions with the provider team and/or Medical Director of UR.
- Performs appropriate and accurate initial admission (episode day one) and concurrent utilization reviews as guided by InterQual Criteria and UR Department workflows on all observation inpatient and extended recovery admissions as required based on Emory Healthcares Utilization Management Plan and the UR Departments processes.
- Ensures that all InterQual reviews are supported with provider team documentation and/or clinical data.
- When appropriate the UR Specialist will utilize the UR Departments Severity of Illness/Intensity of Service template to document the medical necessity of the admission or continued stay.
- While conducting utilization reviews will identify any Avoidable Delays and accurately document the delay(s) based on the workflow.
- Follow the UR Department denial workflows as appropriate.
- Prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital.
Compliance:
- Will identify and complete Medicare Outpatient Observation Notices (MOON) Medicare Change of Status Notice (MCSN) Condition Code 44s and Medicare Hospital Issued Notices of Non-Coverage (HINNs) for Medicare beneficiaries as appropriate.
- Ensures compliance with all state of Georgia and Federal regulatory requirements as designated in Emory Healthcares Utilization Management Plan.
- Maintains all required annual competencies metrics and fully participate and engage in department process improvements.
Collaboration:
- Responsible for timely communication to the provider team and interdisciplinary team as it relates to patient class designation and medical necessity of an admission or continued stay on individual patient basis based on UR Department workflows.
- In a team effort the UR Specialist will work closely with the UR Departments Case Management Authorization Specialist IP to ensure that authorized days and patient actual LOS are reconciled to ensure appropriate reimbursement for services provided.
- Responsible for communicating medical necessity denials for in-house patients to the Medical Director of UR and when designated to the provider team.
- Serves as a resource to the provider team Interdisciplinary Care Team and patient to explain external UR regulations.
- Provides effective and efficient proactive communication to internal and external customers.
- Assists in collaborative efforts with the Case Management Department Revenue Cycle Physician Advisors and other required departments.
Additional Responsibilities:
- Travel: Less than 10% of the time may be required. Work Type: This position is a remote position outside traditional office often from home or another remote setting.
Minimum Qualifications:
- Education - Associate degree in nursing.
- Experience - Minimum of 5 years of recent acute hospital experience or a minimum of two years of previous utilization review experience.
- Licensure - Must have a valid active unencumbered Registered Nurse license approved by the Georgia Licensing Board.
- Skills - Must meet all quality and productivity expectations and successfully complete yearly competencies.
Preferred Qualifications:
- Education - Bachelors degree in Nursing strongly preferred. Certification - Case Management certification preferred.
- Skills - InterQual Level of Care Criteria experience.
- Previous utilization review experience strongly preferred.
JOIN OUR TEAM TODAY! Emory Healthcare (EHC) part of Emory University (EUV) is the most comprehensive academic health system in Georgia and the first and only in Georgia with a Magnet designated ambulatory practice. We are made up of 11 hospitals-4 Magnet designated the Emory Clinic and more than 425 provider locations. The Emory Healthcare Network established in 2011 is the largest clinically integrated network in Georgia with more than 3450 physicians concentrating in 70 different subspecialties.
Additional Details
Emory is an equal opportunity employer and qualified applicants will receive consideration for employment without regard to race color religion sex national origin disability protected veteran status or other characteristics protected by state or federal law.
Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcares Human Resources at . Please note that one weeks advance notice is preferred.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
