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Role 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.

• 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 Healthcare's Utilization Management Plan and the UR Department’s processes.
  • Ensures that all InterQual reviews are supported with provider team documentation and/or clinical data.
  • When appropriate, utilizes the UR Department's Severity of Illness/Intensity of Service template to document the medical necessity of the admission or continued stay.
  • Identifies any Avoidable Delays and accurately documents the delay(s) based on the workflow.
  • Follows the UR Department’s denial workflows as appropriate.
  • Prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital.
• Compliance:
  • Identifies and completes 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 Healthcare's Utilization Management Plan.
  • Maintains all required annual competencies, metrics, and fully participates and engages 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.
  • Works closely with the UR Department's Case Management Authorization Specialist IP to ensure that authorized days and patient actual LOS are reconciled to ensure appropriate reimbursement for services provided.
  • Communicates 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:
  • Ability to multi-task in a fast-paced environment while efficiently handling multiple priorities and ensuring deadlines are met.
  • Performs other duties and tasks as assigned.

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.

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.

Requirements

• Education: Bachelor's degree in Nursing strongly preferred.
• Certification: Case Management certification preferred.
• Skills: InterQual Level of Care Criteria experience. Previous utilization review experience strongly preferred.

Benefits

• 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.

Company Description

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 Healthcare’s Human Resources at careers@emoryhealthcare.org. Please note that one week's advance notice is preferred.