Utilization Review Specialist Registered Nurse / RN

The Emory Healthcare Network encompasses teams of providers at our locations across Georgia, including Emory University Hospital, Emory University Hospital Midtown, Emory University Orthopaedics & Spine Hospital and the Wesley Woods Center; Emory Saint Joseph's Hospital and Emory Johns Creek Hospital; Emory Clinic; and the Emory Healthcare Network physicians, ranging from primary to specialty care providers. Through our integrated, collaborative care network, we are dedicated to providing the standard of care that our patients expect and deserve. Our researchers are discovering what’s next in medicine, and our physicians and care teams are putting that research to use to improve the health of our community today. From our experts at the Winship Cancer Institute of Emory University, the state’s ONLY National Cancer Institute-designated cancer center, to the specialists at our Orthopaedics & Spine Center and our network of hundreds of primary care physicians, our team is 17,000 strong and committed to the health of our community.

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, the UR Specialist will utilize the UR Department's 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¿s denial workflows as appropriate. 8. 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 Healthcare's 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 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. 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: 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.