Utilization Review Specialist

Overview

Be inspired. Be rewarded. Belong. At Emory Healthcare.

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 one!
• Student Loan Repayment Assistance & Reimbursement Programs
• Family-focused benefits
• Wellness incentives
• Ongoing mentorship, development, and leadership programs… and more!

The Utilization Review (UR) Specialist is a Registered Nurse responsible for conducting thorough medical necessity reviews to assist with determining appropriate patient class designation. The UR Specialist will perform timely and comprehensive reviews of the patient chart utilizing Inter Qual Criteria accurately in conjunction with the UR Department workflows/processes, clinical nursing judgement, and when necessary, discussions with the provider team and/or Medical Director of UR.

Operational Support:

1. Conducts thorough medical necessity reviews to assist with determining appropriate patient class designation.
2. Performs timely and comprehensive reviews of the patient chart utilizing Inter Qual Criteria accurately in conjunction with the UR Department workflows/processes, clinical nursing judgement, and when necessary, discussions with the provider team and/or Medical Director of UR. 3. Performs appropriate and accurate initial, admission (episode day one) and concurrent utilization reviews as guided by Inter Qual Criteria and UR Department workflows on all observation, inpatient, and extended recovery admissions as required based on Emory Healthcare's Utilization Management Plan and the UR Department's processes.

4. Ensures that all Inter Qual reviews are supported with provider team documentation and/or clinical data.
5. When appropriate, the UR Specialist will utilize the UR Department's Severity of Illness/Intensity of Service template to document the medical necessity of the admission or continued stay.
6. While conducting utilization reviews, will identify any Avoidable Delays and accurately document the delay(s) based on the workflow.
7. Follow the UR Department's denial workflows as appropriate.
8. Prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital.

Compliance:

1. Will 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.
2. Ensures compliance with all state of Georgia and Federal regulatory requirements as designated in Emory Healthcare's Utilization Management Plan.
3. Maintains all required annual competencies, metrics, and fully participate and engage in department process improvements.

Collaboration:

1. Responsible for timely communication 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 based on UR Department workflows. 2. In a team effort, the UR Specialist will work closely with the UR Department's Case Management Authorization Specialist IP to ensure that authorized days and patient actual LOS are reconciled to ensure appropriate reimbursement for services provided.

3. Responsible for communicating medical necessity denials for in-house patients to the Medical Director of UR, and when designated to the provider team.
4. Serves as a resource to the provider team, Interdisciplinary Care Team, and patient to explain external UR…