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Emory Healthcare/Emory University Utilization Review Nurse, Social Services at Midtown in Atlanta, Georgia


The shift for this position is 8a-4:30p

JOB DESCRIPTION: The Utilization Review Nurse (UR RN) is responsible for conducting medical necessity reviews by utilizing Millman and Interqual Guidelines in conjunction with a review of the patient chart, clinical nursing judgement, and discussions with the attending physician and/or physician advisor. The UR RN 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 RN will ensure that all reviews are completed timely, accurately, and thoroughly by ensuring criteria guidelines applied are addressed in the clinical review. Responsible for timely communication to the Physicians and Interdisciplinary team as it relates to criteria guidelines and status designation on an individual patient basis. Ensures 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 and that authorized days and patient actual LOS are reconciled in order to maximize reimbursement for the services provided. 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. Initiates and facilitates 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. Issues and administers notices of non-coverage and potential liability to patients in accordance with predetermined regulations, policies, and procedures. 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. 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. Ensures 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. Ensures compliance with all third party payers and federal and state regulatory agencies. Ensures proper use of Case Management Systems and workflows. Actively participates in process improvement initiatives by sharing thoughts and ideas in a constructive manner. Meets all quality and productivity expectations and successfully complete yearly competencies. Must obtain 4 CEU credits per year, related directly to core job functions, in addition to yearly competencies.

MINIMUM QUALIFICATIONS: Must have a valid, active unencumbered Nursing license or temporary permit approved by the Georgia Licensing Board. Bachelors degree in nursing preferred or actively being pursued. 2 years recent healthcare experience required.

PHYSICAL REQUIREMENTS (MediumMax 25lbs): up to 25 lbs, 0-33% of the work day (occasionally); 11-25 lbs, 34-66% of the workday (frequently); 01-10 lbs, 67-100% of the workday (constantly); Lifting 25 lbs max; Carrying of objects up to 25 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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Division Emory Univ Hosp-Midtown

Campus Location Atlanta, GA, 30308

Campus Location US-GA-Atlanta

Department WEM Social Services

Job Type Regular Full-Time

Job Number 93248

Job Category Nursing

Schedule 8a-4:30p

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.