Analyst (RN), Utilization Management
At Emory Healthcare, we integrate science and caring to change the face of health care. Our team members are courageous individuals who are willing to challenge the status quo and help find solutions to complex problems. We're empowered to influence change for, and with, our patients, their families, the community and each other.
As one of the leading academic medical systems, we're eager to share what we learn with hospitals around the country, and the world. 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.
We're defining a new standard of care for humankind. Are YOU ready to join us?
This position is PRN with a shift of 8am - 4:30pm.
- Notifies attending physicians and Interdisciplinary Patient Care Teams of all denied and pended for medical review days.
- Complies with established policies and procedures and implements appropriate changes to the Utilization Management process as directed.
- Takes action to achieve annual departmental goals. Provides information including thorough, accurate and timely clinical updates to comply with regulations of third party payors and federal and state regulatory agencies and to obtain approvals of LOS and facilitate accurate payment of claims.
- Participates in discharge planning. Attends Interdisciplinary Patient Care Team meetings and assigns tentative LOS on initial review of patient record. Initiates referrals to Social Services as appropriate.
- Assumes responsibility for identifying impediments and communicates and/or addresses barriers to timely discharge.
- Reviews each hospital admission in accordance with nationally recognized criteria and department policies to determine the medical necessity of admission and appropriate LOS.
- Intervenes as required with physicians and Interdisciplinary Patient Care Teams to facilitate achievement of targeted LOS. Communicates and provides financial data regarding the patient's hospital admission and LOS when appropriate.
- Issues and administers notices of non-coverage and potential of liability to clients in accordance with predetermined regulations, policies and procedures.
- Collects and records required Utilization Management information for appropriate management of the patients in the units to which they are assigned.
- Maintains accurate, legible, confidential documents and records pertaining to medical reviews. Facilitates the review process by ensuring the timely delivery of materials to the appropriate personnel.
- Serves as a resource to Interdisciplinary Patient Care Teams and physicians for the interpretation of external regulations and organizational policies and procedures pertaining to the utilization Management process.
- Communicates nationally recognized criteria as appropriate. Utilizes medical knowledge as an advocate for the patient to provide pertinent information to third party payors.
- Serves as a liaison to assigned nursing units to facilitate the Utilization Management process and to ensure the continuity of patient care.
- Identifies LOS and/or insurance issues and informs Interdisciplinary Patient Care Team for response.
- Works with third party payor representatives as an organizational representative. Facilitates MD to MD reviews as needed. Maintains an effective flow of information between the nursing units, Social Services, physicians, Medical Records, Business Office and third party payors to facilitate appropriate lengths of stay (LOS) and to ensure appropriate reimbursement and coverage.
- Identifies, addresses and reports all quality issues to appropriate parties in a professional manner. MINIMUM QUALIFICATIONS:
- Graduate of an accredited nursing program. Currently licensed as a Registered Nurse in the state of Georgia. Two years of recent health care experience (within the past five years) and one year of experience in utilization management, quality improvement, or discharge planning.
- A bachelor's degree in nursing or related health care field preferred.