Utilization Management Clinical Review Registered Nurse Specialist / RN

Emory Healthcare•Johns Creek, GA

5h•$47 - $55•Remote

About The Position

The Utilization Management (UM) Clinical Review RN Specialist is a Registered Nurse responsible for conducting medical necessity reviews to help determine appropriate patient class designation. The role includes timely, comprehensive patient-chart reviews using InterQual Criteria, UM Department workflows and processes, and clinical nursing judgment. The nurse may consult with the provider team or the UM Medical Director when needed. The position is remote, outside a traditional office setting, often from home or another remote location. Travel may be required less than 10% of the time. The role supports operational, regulatory-compliance, and interdisciplinary collaboration activities. The specialist conducts initial, admission (episode day one), and concurrent utilization reviews for observation, inpatient, and extended-recovery admissions as required by Emory Healthcare’s Utilization Management Plan and department processes. The specialist documents review findings, identifies avoidable delays, follows denial workflows, supports appropriate reimbursement, and communicates patient-class and medical-necessity determinations to relevant care teams and stakeholders. Emory Healthcare describes its benefits and employee support as including comprehensive health benefits starting day one, student loan repayment assistance and reimbursement programs, family-focused benefits, wellness incentives, and ongoing mentorship, development, and leadership programs. Emory is an equal opportunity employer and provides reasonable accommodations to qualified individuals with disabilities upon request.

Requirements

Associate degree in nursing.
At least 5 years of recent acute hospital experience or at least 2 years of previous utilization management experience.
Valid, active, unencumbered Registered Nurse license approved by the Georgia Licensing Board.
Meet quality and productivity expectations and successfully complete yearly competencies.

Nice To Haves

Bachelor’s degree in Nursing strongly preferred.
Case Management certification preferred.
InterQual Level of Care Criteria experience.
Previous utilization review experience strongly preferred.

Responsibilities

Conduct thorough medical necessity reviews to assist with determining appropriate patient class designation.
Perform timely and comprehensive patient-chart reviews using InterQual Criteria, UM Department workflows and processes, clinical nursing judgment, and discussions with the provider team or UM Medical Director when necessary.
Perform appropriate and accurate initial, admission (episode day one), and concurrent utilization reviews for observation, inpatient, and extended-recovery admissions as required by the Utilization Management Plan and department processes.
Ensure InterQual reviews are supported by provider-team documentation and/or clinical data.
Use the UM Department’s Severity of Illness/Intensity of Service template when appropriate to document medical necessity of an admission or continued stay.
Identify and accurately document avoidable delays according to workflow.
Follow UM Department denial workflows as appropriate.
Prioritize work with minimal guidance to support optimal reimbursement and avoid financial risk to patients and the hospital.
Identify and complete Medicare Outpatient Observation Notices (MOON), Medicare Change of Status Notices (MCSN), Condition Code 44s, and Medicare Hospital Issued Notices of Non-Coverage (HINNs) for Medicare beneficiaries as appropriate.
Ensure compliance with applicable Georgia and federal regulatory requirements designated in Emory Healthcare’s Utilization Management Plan.
Maintain required annual competencies and metrics, and participate and engage in department process improvements.
Communicate timely with provider and interdisciplinary teams about patient-class designation and medical necessity of admissions or continued stays, following department workflows.
Work with the UM Department’s Utilization Management Operations Specialist to reconcile authorized days with actual patient length of stay to support appropriate reimbursement.
Communicate medical-necessity denials for in-house patients to the UM Medical Director and, when designated, to the provider team.
Serve as a resource to provider teams, the Interdisciplinary Care Team, and patients regarding external UM regulations.
Provide proactive, effective, and efficient communication to internal and external customers.
Collaborate with Case Management, Revenue Cycle, Physician Advisors, and other required departments.
Multitask in a fast-paced environment, manage multiple priorities, and meet deadlines.
Perform other duties and tasks as assigned.