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 

The Utilization Review (UR) Specialist is a Registered Nurse responsible for conducting thorough medical necessity reviews to assist with determining appropriate patient class designation. The UR Specialist will:

• Perform timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with the UR Department workflows/processes, clinical nursing judgement, and when necessary, discussions with the provider team and/or Medical Director of UR.
• Conducts thorough medical necessity reviews to assist with determining appropriate patient class designation. 
• Performs timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with the UR Department workflows/processes, clinical nursing judgement, and when necessary, discussions with the provider team and/or Medical Director of UR. 
• Performs appropriate and accurate initial, admission (episode day one) and concurrent utilization reviews as guided by InterQual Criteria and UR Department workflows on all observation, inpatient, and extended recovery admissions as required based on Emory Healthcare's Utilization Management Plan and the UR Department processes.
• Ensures that all InterQual reviews are supported with provider team documentation and/or clinical data. 
• When appropriate, the UR Specialist will utilize the UR Department's Severity of Illness/Intensity of Service template to document the medical necessity of the admission or continued stay. 
• While conducting utilization reviews, will identify any Avoidable Delays and accurately document the delay(s) based on the workflow. 
• Follow the UR Department's denial workflows as appropriate. 
• Prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital.
• Will identify and complete Medicare Outpatient Observation Notices (MOON), Medicare Change of Status Notice (MCSN), Condition Code 44s and Medicare Hospital Issued Notices of Non-Coverage (HINNs) for Medicare beneficiaries as appropriate.
• Ensures compliance with all state of Georgia and Federal regulatory requirements as designated in Emory Healthcare's Utilization Management Plan.
• Maintains all required annual competencies, metrics, and fully participate and engage in department process improvements.
• Responsible for communicating medical necessity denials for in-house patients to the Medical Director of UR, and when designated to the provider team.
• Serves as a resource to the provider team, Interdisciplinary Care Team, and patient to explain external UR regulations. 
• Provides effective and efficient proactive communication to internal and external customers.
• Assists in collaborative efforts with the Case Management Department, Revenue Cycle, Physician Advisors, and other required departments.

Minimum Qualifications:

• Associate degree in nursing.
• Minimum of 5 years of recent acute hospital experience or a minimum of two years of previous utilization review experience.
• Must have a valid, active unencumbered Registered Nurse license approved by the Georgia Licensing Board.
• Must meet all quality and productivity expectations and successfully complete yearly competencies.
• Preferred Qualifications: Education - Bachelor's degree in Nursing strongly preferred. Certification - Case Management certification preferred.
• InterQual Level of Care Criteria experience.
• Previous utilization review experience strongly preferred.

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.