Utilization Review Specialist

Emory Healthcare • Atlanta, GA

376d

About The Position

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. Our Utilization Review Specialist team is leading the way in shaping the future of health care. We unite to improve lives through innovation, compassion, and an unwavering commitment to achieving unparalleled excellence in patient care.

Requirements

• Registered Nurse (RN) or Master of Social Work (MSW) with experience in utilization review.
• Valid, active unencumbered nursing license or temporary permit approved by the Georgia Licensing board for RNs.
• Minimum of 2 years recent healthcare experience for RNs or MSWs.
• Meet all quality and productivity expectations and complete yearly competencies.

Nice To Haves

• Bachelor's degree in nursing preferred or actively being pursued for RNs.
• Social work licensure in the State of Georgia for MSWs.

Responsibilities

• Conduct medical necessity reviews using Milliman and Interqual Guidelines.
• Perform utilization review for new observation and inpatient admissions.
• Complete concurrent reviews as required by payers.
• Ensure timely, accurate, and thorough completion of reviews.
• Communicate status designations and criteria guidelines to Physicians and the Interdisciplinary team.
• Review patient hospital days for appropriate authorization from payers.
• Reconcile authorized days and actual length of stay to maximize reimbursement.
• Document authorized, unauthorized, or denied days to reduce financial risk.
• Facilitate discussions between RNs and Physicians with payers.
• Issue notices of non-coverage and potential liability to patients.
• Attend interdisciplinary care planning rounds as a liaison between teams.
• Interpret external regulations and organizational policies for the utilization review process.
• Ensure compliance with regulatory requirements for Government and Commercial Payers.

Benefits

• Comprehensive health benefits that start day 1
• Student Loan Repayment Assistance & Reimbursement Programs
• Family-focused benefits
• Wellness incentives
• Ongoing mentorship and leadership programs

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Hospitals
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees