Utilization Review Specialist Registered Nurse

About This Role

Conduct thorough medical necessity reviews as a Utilization Review Specialist Registered Nurse to determine appropriate patient class designation and ensure compliance with regulatory requirements. This role helps optimize reimbursement and minimize financial risk for both patients and the hospital.

Responsibilities

• Conduct thorough medical necessity reviews to assist with determining appropriate patient class designation
• Perform timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with UR Department workflows/processes, clinical nursing judgement, and discussions with the provider team and/or Medical Director of UR
• Perform appropriate and accurate initial, admission (episode day one) and concurrent utilization reviews on all observation, inpatient, and extended recovery admissions as required
• Ensure that all InterQual reviews are supported with provider team documentation and/or clinical data
• Utilize the UR Department's Severity of Illness/Intensity of Service template to document medical necessity of admission or continued stay when appropriate
• Identify any Avoidable Delays while conducting utilization reviews and accurately document the delay(s)
• Follow the UR Department’s denial workflows as appropriate
• Prioritize work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital
• 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
• Ensure compliance with all state of Georgia and Federal regulatory requirements as designated in Emory Healthcare's Utilization Management Plan
• Maintain all required annual competencies, metrics, and fully participate and engage in department process improvements
• Communicate timely 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
• Work closely with the UR Department's Case Management Authorization Specialist IP to ensure that authorized days and patient actual LOS are reconciled for appropriate reimbursement
• Communicate medical necessity denials for in-house patients to the Medical Director of UR, and when designated to the provider team
• Serve as a resource to the provider team, Interdisciplinary Care Team, and patient to explain external UR regulations
• Provide effective and efficient proactive communication to internal and external customers
• Assist in collaborative efforts with the Case Management Department, Revenue Cycle, Physician Advisors, and other required departments

Requirements

• Associate degree in nursing
• Valid, active unencumbered Registered Nurse license approved by the Georgia Licensing Board
• Minimum of 5 years of recent acute hospital experience OR minimum of two years of previous utilization review experience

Qualifications

• Associate degree in nursing
• Minimum of 5 years of recent acute hospital experience or a minimum of two years of previous utilization review experience

Nice to Have

• Bachelor's degree in Nursing
• Case Management certification
• InterQual Level of Care Criteria experience
• Previous utilization review experience

Benefits