Utilization Review Specialist

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Description

The Utilization Review (UR) Specialist is responsible for conducting medical necessity reviews by utilizing Milliman and Interqual Guidelines in conjunction with a review of the patient chart, clinical judgement, and discussions with the attending physician and/or physician advisor.

The UR Specialist will perform utilization review by completing a timely and comprehensive review of all new observation and inpatient admissions for status designation as guided by criteria guidelines, patient presentation, and clinical nursing judgement.

In addition, concurrent reviews will be completed as required by the payers, by accurately applying appropriate criteria sets.

The UR Specialist will ensure that all reviews are completed timely, accurately, and thoroughly by ensuring criteria guidelines applied are addressed in the clinical review.

The UR Specialist is responsible for timely communication to the Physicians and Interdisciplinary team as it relates to criteria guidelines and status designation on an individual patient basis.

The UR Specialist will ensure that patient hospital days are appropriately reviewed in order to obtain the appropriate authorization from the payer in an effort to ensure appropriate payment for services provided.

The UR Specialist will ensure that authorized days and patient actual LOS are reconciled in order to maximize reimbursement for the services provided.

The UR Specialist is responsible for real time communication and documentation of authorized, unauthorized or denied days to the Physician and the care team in order to reduce patient and hospital financial risk.

The UR Specialist will initiate and facilitate RN to RN discussion and/or Physician to Physician discussion with the payers in order to act as an advocate on behalf of the patient and hospital in an effort to reduce non-covered, non-authorized, or denied services.

The UR Specialist will issue and administer notices of non-coverage and potential liability to patients in accordance with predetermined regulations, policies, and procedures.

The UR Specialist attends interdisciplinary care planning rounds and serves as a liaison between the clinical care team, the revenue cycle, and the patient to ensure the continuity of patient care.

The UR Specialist serves as a resource to the Physician, Interdisciplinary Care Team, and patient for the interpretation of external regulations and organizational policies and procedures as it pertains to the utilization review process.

The UR Specialist will ensure compliance with all regulatory requirements as it relates to Government and Commercial Payers and designated Utilization Review Plans, as submitted to the State of Georgia.

The UR Specialist will ensure compliance with all third party payers and federal and state regulatory agencies.

The UR Specialist will ensure proper use of Case Management Systems and workflows. MINIMUM QUALIFICATIONS:

This role requires a professional with a strong background in healthcare, either as a Registered Nurse (RN) or a Master of Social Work (MSW) with experience in utilization review.

RNAs must hold a valid, active unencumbered nursing license or temporary permit approved by the Georgia Licensing board.

A minimum of 2 years recent healthcare experience is required for RNÂ s or MSWs.

Must meet all quality and productivity expectations and successfully complete yearly competencies.

Preferred Qualifications: RN - Bachelors degree in nursing preferred or actively being pursued. MSW - Social work licensure in the State of Georgia is 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 3,450 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 Healthcare’s Human Resources at . Please note that one week's advance notice is preferred.

Regular Part-Time