Inpatient Utilization Review Registered Nurse / RN

Overview Be inspired . Be rewarded. Belong. At Emory Healthcare. Benefits At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be . We provide : Comprehensive health benefits that start day 1 Student Loan Repayment Assistance & Reimbursement Programs Family-focused benefits Wellness incentives Ongoing mentorship , development, and leadership programs And more Description We're seeking an Inpatient Registry Utilization Review Nurse (PRN) who is responsible for conducting medical necessity reviews by utilizing Milliman 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. This individual 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. 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. 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. Will ensure that authorized days and patient actual LOS are reconciled in order to maximize reimbursement for the services provided. 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. 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. Issue and administer 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. 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. Ensure compliance with all third party payers and federal and state regulatory agencies. Ensure proper use of Case Management Systems and workflows. 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. Must meet all quality and productivity expectations and successfully complete yearly competencies. Must be willing to work at least 4 shifts / mo. 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 careers@emoryhealthcare.org . Please note that one week's advance notice is preferred.