Emory Healthcare·Decatur, Georgia
The UR Specialist conducts medical necessity reviews using InterQual Criteria to determine appropriate patient class designations. They collaborate with provider teams and the Medical Director to ensure accurate reimbursement and compliance with regulatory requirements.
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.
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 regulations. 5. Provides effective and efficient proactive communication to internal and external customers. 6. Assists in collaborative efforts with the Case Management Department, Revenue Cycle, Physician Advisors, and other required departments.
Additional
Duties: 1. Ability to multi-task in a fast-paced environment while efficiently handling multiple priorities and ensuring deadlines are met. 2. Performs other duties and tasks as assigned.
Less than 10% of the time may be required.
Work
Type: This position is a remote position outside traditional office, often from home or another remote setting.
Education - Associate degree in nursing. Experience - Minimum of 5 years of recent acute hospital experience or a minimum of two years of previous utilization review experience. Licensure - Must have a valid, active unencumbered Registered Nurse license approved by the Georgia Licensing Board. Skills - Must meet all quality and productivity expectations and successfully complete yearly competencies.
Education - Bachelor's degree in Nursing strongly preferred. Certification - Case Management certification preferred. Skills - InterQual Level of Care Criteria experience. Previous utilization review experience strongly preferred. 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.
Requires an Associate degree in nursing and a valid Georgia RN license. Candidates must have at least 5 years of acute hospital experience or 2 years of utilization review experience.
Market context
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