JOB DESCRIPTION: Manages, plans, directs, and monitors the Utilization and Clinical Resource Management functions and coordinates activities with other components of the department to ensure appropriate allocation of hospital resources for all Emory Healthcare facilities. Assists in planning, administering, and monitoring the department's capital equipment and operations budget. Investigates variances and takes corrective actions to maintain expenses within approved levels. Manages the admissions review process by overseeing preadmission certifications, verifying the medical necessity of hospitalization and continued stay reviews. Ensures that patient charts are reviewed using established criteria to determine the medical necessity of admission, appropriate length of stay and proper utilization of resources. Manages denial and appeals process with third party payors. Supervises and monitors staff performance. Assists in the development of utilization review and clinical resource management programs to meet the changing requirements of third party payors. Trains new employees and plans, coordinates, and conducts in-service educational programs pertaining to utilization management. Serves as organizational expert on clinical resources/utilization management issues. Coordinates and assists with departmental and organizational quality improvement activities to ensure compliance with all regulatory standards. Analyzes outcome data and customer satisfaction data and recommends process and system improvements. Serves as a back up to Assistant Director of Social Services for the Emory Healthcare System. Develops and implements strategic goals and objectives to ensure regulatory compliance. Coordinates and supervises staff services for continuous improvement of operations. Performs other responsibilities as required.
MINIMUM QUALIFICATIONS: Current licensure as a Registered Nurse in the state of Georgia. Requires three years of clinical nursing experience and three years experience in a utilization review program; two must be in a managerial capacity. Bachelor's in Nursing or health related field. Waived for five years utilization management experience. BLS, ACLS, and Healthcare Provider certifications required.
PHYSICAL REQUIREMENTS (MediumMax 25lbs): up to 25 lbs, 0-33% of the work day (occasionally); 11-25 lbs, 34-66% of the workday (frequently); 01-10 lbs, 67-100% of the workday (constantly); Lifting 25 lbs max; Carrying of objects up to 25 lbs; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks.
ENVIRONMENTAL FACTORS: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure Bio-hazardous waste Chemicals/gases/fumes/vapors Communicable diseases Electrical shock, Floor Surfaces, Hot/Cold Temperatures, Indoor/Outdoor conditions, Latex, Lighting, Patient care/handling injuries, Radiation, Shift work, Travel may be required. Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.