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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.RN¿s 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 RN¿s or MSWs.Must meet all quality and productivity expectations and successfully complete yearly competencies.Preferred Qualifications: ¿ RN - Bachelor¿s 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 DetailsSupporting a diverse, equitable and inclusive culture. Emory Healthcare (EHC) is dedicated to providing equal opportunities and access to all individuals regardless of race, color, religion, ethnic or national origin, gender, genetic information, age, disability, sexual orientation, gender identity, gender expression and/or veteran's status. EHC does not discriminate on the basis of any factor stated above or prohibited under applicable law. EHC respects, values, and celebrates the unique perspectives and backgrounds of all individuals. EHC aspires to create an environment of collaboration and true belonging for all our patients and team members. Emory Healthcare (EHC) is committed to achieving a diverse workforce through equal opportunity and nondiscrimination policy in all aspects of employment including recruitment, hiring, promotions, transfers, discipline, terminations, wage and salary administration, benefits, and training.
ACCOMODATIONS: EHC will provide reasonable accommodations to qualified individuals with disabilities upon request. To request this document in an alternate format or to request a reasonable accommodation, please contact the Office of Diversity, Equity, and Inclusion.”
PHYSICAL REQUIREMENTS: (Medium-Heavy) 36-75 lbs, 0-33% of the work day (occasionally); 20-35 lbs, 34-66% of the workday; (frequently); 10-20 lbs, 67-100% of the workday (constantly); Lifting 75 lbs max; Carrying of objects up to 35 lbs; Occasional to frequent standing & walking; Occasional sitting; Close eye work (computers, typing, reading, writing); Physical demands may vary depending on assigned work area and work tasks.
ENVIRONMENTAL FACTORS: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure; Bio-hazardous waste Chemicals/gases/fumes/vapors; Communicable diseases; Electrical shock; Floor Surfaces; Hot/Cold Temperatures; Indoor/Outdoor conditions; Latex; Lighting; Patient care/handling injuries; Radiation; Shift work; Travel may be required; Use of personal protective equipment, including respirators; environmental conditions may vary depending on assigned work area and work tasks.
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