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Overview

Heart. Soul. Expertise. That’s what defines an Emory nurse. No matter where you are in your nursing career, when you chose this distinguished profession, you chose to change lives. We are proud to be the only health system in Georgia with four Magnet®- recognized hospitals: Emory University Orthopaedics & Spine Hospital, Emory Saint Joseph’s Hospital, Emory University Hospital, and Emory Johns Creek Hospital.

We’re looking for passionate nurses who are ready to join a team that’s redefining quality nursing care. As integral members of high-functioning, inter-professional teams, Emory Healthcare’s nurses are on the frontline of care in our hospitals and operate with a full complement of specialties and the ability to care for medically complex patients.

We’ve got the backing, knowledge, experience and permission to lead the way in developing new and better approaches to preventing and treating disease, and our patients get treatments years before anyone else.

Are YOU ready to join us?

Description

JOB DESCRIPTION:

• Responsible for the utilization review and technical appeal of clinically related denials (concurrent and retro) achieving optimal financial outcomes for the hospital.

• Expert utilization and application of InterQual® and Milliman® criteria. Represents Emory providing formal appeals via letter and phone to managed care payers.

• Appeal processes include but are not limited to review of utilization review, billing, coding, charging, and clinically related technical errors.

• Creates and designs databases documenting clinical and technical denial information which can then be further analyzed.

• Provides denial reports on a monthly, quarterly, and requested basis to the Care Management Department, Patient Financial Services, Managed Care Contracting, Revenue Cycle, and hospital leadership including the CEO.

• Reports reflect hospital trends regarding patterns of denials and outcomes of appeals using a data driven approach.

• Uses financial analysis to develop proactive strategies for denials reduction.

• Coordinates activities and strategies with the Care Management Department, Patient Access, Billing, Managed Care, and Physician Advisors.

• Expert knowledge of every current Saint Joseph's managed care contract, informing the Managed Care Contracting Department of patterns, trends and critical incidents related to payment denials.

• Represents Saint Joseph's in identification, negotiation, and problem solving in conjunction with the Managed Care Contracting Department.

• Prioritizes assignments to avoid financial risk. Serves as a financial resource to team.

• Expert knowledge base regarding payer regulations and industry trends.MINIMUM QUALIFICATIONS:

• Minimum of 3 - 5 years of varied hospital and Utilization Review experience.

• Includes minimum two years experience in insurance setting with focus on Managed Care (preferred).

• Expert in database functions and spreadsheets.

• Graduate of an accredited School of Nursing and have a valid, active unencumbered Nursing license or temporary permit approved by the Georgia Licensing Board.

• Certification as CCM, HIAA, HFMA and/or Inpatient Coding preferred.

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Division Emory Healthcare Inc.

Campus Location Atlanta, GA, 30308

Campus Location US-GA-Atlanta

Department EHI Revenue Management

Job Type Regular Full-Time

Job Number 64973

Job Category Revenue Cycle & Managed Care

Schedule 7a-3:30p

Standard Hours 40 Hours

Emory Healthcare is an Equal Employment Opportunity employer committed to providing equal opportunity in all of its employment practices and decisions. Emory Healthcare prohibits discrimination, harassment, and retaliation in employment based on race, color, religion, national origin, sex, sexual orientation, gender identity or expression, pregnancy, age (40 and over), disability, citizenship, genetic information, service in the uniformed services, veteran status or any other classification protected by applicable federal, state, or local law.