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, and leadership programs  
• And more

We're seeking under the direction of the Utilization Management Appeals Professional, Registered Nurse is responsible for managing clinical denials and appeals.

• Responsibilities include reviewing medical records, denial reason(s), preparing, developing, and submitting formal written appeal letters to third party payers within the required timeframe, or according to established schedules or workflow requirements.
• Will represent Emory Healthcare in Administrative Law Judge (ALJ) hearings and if required, Medicare Appeals Council.
• Primary duties and responsibilities: Participates in external reviews such as Medicare Recovery Audit Program or other third-party audit programs and defends Emory Healthcares decisions as appropriate through written appeals as needed.
• Conducts complete and accurate retrospective reviews and audits of hospital records to determine if patient class (level of care) was appropriate and sufficiently documented prior to recommending an appeal or change in patient class.
• Coordinates third party appeals with the physician advisor team when needed. -Uses sound clinical judgement, reasoning, and utilizes knowledge of established practices, procedures, policies and regulations before decision making.
• Provides data to external parties as requested while ensuring HIPAA compliance.
• Educates all members of the patient care team, Medical Directors and Utilization Management leadership regarding trends in clinical documentation needs and reimbursement issues.
• Responsibilities also include identifying opportunities to enhance payer and provider process improvements to ensure optimal and appropriate reimbursement for services provided.
  
  MINIMUM QUALIFICATIONS:
• License - Must have a valid, active unencumbered Registered Nurse license or temporary permit approved by the Georgia Licensing Board.
• Education - Bachelor's degree in nursing with 5 years of acute care experience required.
• Experience - At least 3 years of experience in Utilization Review or Care Management is required or previous appeal experience.
• Working knowledge of level of care criteria and knowledge of state and federal regulations/polices is required.
• Preferred Qualifications: -Previous medical necessity appeal experience is preferred. Case Management certification (CCM or ACM) preferred.
• Written and oral communication must be clear, concise and professional.
• Knowledge and ability to collaborate with clinical, operational, and financial areas required.
  
  JOIN OUR TEAM TODAY! Emory Healthcare (EHC), part of Emory University (EUV), is the most comprehensive academic health system in Georgia and the first and only in Georgia with a Magnet® designated ambulatory practice. We are made up of 11 hospitals-4 Magnet® designated, the Emory Clinic, and more than 425 provider locations. The Emory Healthcare Network, established in 2011, is the largest clinically integrated network in Georgia, with more than 3,450 physicians concentrating in 70 different subspecialties.

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.