RN Utilization Management Analyst, EUH, 8am-5pm - Emory Healthcare - Atlanta, GA

RN Utilization Management Analyst, EUH, 8am-5pm - Emory Healthcare - Atlanta, GA -

Notifies attending physicians and Interdisciplinary Affected person Care Groups of all denied and pended for medical evaluation days. Complies with established insurance policies and procedures and implements applicable modifications to the Utilization Management course of as directed. Takes motion to realize annual departmental objectives. Offers info together with thorough, correct and well timed medical updates to adjust to laws of third social gathering payors and federal and state regulatory businesses and to acquire approvals of LOS and facilitate correct cost of claims.

Participates in discharge planning. Attends Interdisciplinary Affected person Care Staff conferences and assigns tentative LOS on preliminary assessment of affected person report. Initiates referrals to Social Providers as applicable. Assumes duty for figuring out impediments and communicates and/or addresses limitations

to well timed discharge. Critiques every hospital admission in accordance with nationally acknowledged standards and division insurance policies to find out the medical necessity of admission and applicable LOS. Intervenes as required with physicians and Interdisciplinary Affected person Care Groups to facilitate achievement of focused LOS. Communicates and offers monetary knowledge relating to the affected person’s hospital admission and LOS when applicable. Points and administers notices of non-protection and potential of legal responsibility to shoppers in accordance with predetermined laws, insurance policies and procedures.

Collects and data required Utilization Management info for applicable management of the sufferers within the models to which they’re assigned. Maintains correct, legible, confidential paperwork and data pertaining to medical critiques. Facilitates the evaluation course of by making certain the well timed supply of

supplies to the suitable personnel.

Serves as a useful resource to Interdisciplinary Affected person Care Groups and physicians for the interpretation of exterior laws and organizational insurance policies and procedures pertaining to the utilization Management course of. Communicates nationally acknowledged standards as applicable. Makes use of medical information as an advocate for the affected person to offer pertinent info to 3rd social gathering payors. Serves as a liaison to

assigned nursing models to facilitate the Utilization Management course of and to make sure the continuity of affected person care. Identifies LOS and/or insurance points and informs Interdisciplinary Affected person Care Staff for response. Works with third get together payor representatives as an organizational consultant. Facilitates MD to MD evaluations as wanted. Maintains an efficient circulate of data between the nursing models, Social

Providers, physicians, Medical Data, Enterprise Workplace and third social gathering payors to facilitate applicable lengths of keep (LOS) and to make sure applicable reimbursement and protection. Identifies, addresses and studies all high quality points to applicable events in knowledgeable method.

MINIMUM QUALIFICATIONS: Graduate of an accredited nursing program. Presently licensed as a Registered Nurse within the state of Georgia. Two years of current well being care expertise (inside the previous 5 years) and one yr of expertise in utilization management, high quality enchancment, or discharge planning. A bachelor’s diploma in nursing or associated well being care area most popular.

PHYSICAL REQUIREMENTS (MediumMax 25lbs): as much as 25 lbs, Zero-33% of the work day (sometimes); 11-25 lbs, 34-66% of the workday (steadily); 01-10 lbs, 67-100% of the workday (always); Lifting 25 lbs max; Carrying of objects as much as 25 lbs; Occasional to frequent standing & strolling, Occasional sitting, Shut eye work (computer systems, typing, studying, writing), Bodily calls for might differ relying on assigned work space and work duties.

ENVIRONMENTAL FACTORS: Elements affecting setting circumstances might differ relying on the assigned work space and duties. Environmental exposures embrace, however will not be restricted to: Blood-borne pathogen publicity Bio-hazardous waste Chemical compounds/gases/fumes/vapors Communicable illnesses Electrical shock, Flooring Surfaces, Scorching/Chilly Temperatures, Indoor/Outside circumstances, Latex, Lighting, Affected person care/dealing with accidents, Radiation, Shift work, Journey could also be required. Use of private protecting gear, together with respirators, environmental circumstances might range relying on assigned work space and work duties.

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