Inpatient Utilization Review Registered Nurse PRN / RN

Emory Healthcare•Atlanta, GA

About The Position

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 1 Student Loan Repayment Assistance & Reimbursement Programs Family-focused benefits Wellness incentives Ongoing mentorship, development, leadership programs and... more! Description JOB DESCRIPTION: The Registry Utilization Review Nurse (PRN) 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. The UR RN (PRN) 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 (PRN) will ensure that all reviews are completed timely, accurately, and thoroughly by ensuring criteria guidelines applied are addressed in the clinical review. The UR RN (PRN) is responsible for timely communication to the Physicians and Interdisciplinary team as it relates to criteria guidelines and status designation on an individual patient basis. The UR RN (PRN) 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. The UR RN (PRN) will ensure that authorized days and patient actual LOS are reconciled in order to maximize reimbursement for the services provided. The UR RN (PRN) 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. The UR RN (PRN) will 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. The UR RN (PRN) will issue and administer notices of non-coverage and potential liability to patients in accordance with predetermined regulations, policies, and procedures. The UR RN (PRN) 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. The UR RN (PRN) 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. The UR RN will (PRN) 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. The UR RN (PRN) will ensure compliance with all third party payers and federal and state regulatory agencies. The UR RN (PRN) will ensure proper use of Case Management Systems and workflows.

Requirements

Must have a valid, active unencumbered Nursing license or temporary permit approved by the Georgia Licensing Board
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

Nice To Haves

Bachelors degree in nursing preferred or actively being pursued

Responsibilities

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
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
complete concurrent reviews 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
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
ensure 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
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
attend 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