Utilization Management Analyst RN, PRN
Company: Emory Healthcare
Posted on: May 16, 2022
The shift for this PRN position is 8a-4:30p
- Notifies attending physicians and Interdisciplinary Patient
Care Teams of all denied and pended for medical review
- Complies with established policies and procedures and
implements appropriate changes to the Utilization Management
process as directed.
- Takes action to achieve annual departmental goals.
- Provides information including thorough, accurate and timely
clinical updates to comply with regulations of third party payors
and federal and state regulatory agencies and to obtain approvals
of LOS and facilitate accurate payment of claims.
- Participates in discharge planning.
- Attends Interdisciplinary Patient Care Team meetings and
assigns tentative LOS on initial review of patient record.
- Initiates referrals to Social Services as appropriate.
- Assumes responsibility for identifying impediments and
communicates and/or addresses barriers to timely
- Reviews each hospital admission in accordance with nationally
recognized criteria and department policies to determine the
medical necessity of admission and appropriate LOS.
- Intervenes as required with physicians and Interdisciplinary
Patient Care Teams to facilitate achievement of targeted
- Communicates and provides financial data regarding the
patient's hospital admission and LOS when appropriate.
- Issues and administers notices of non-coverage and potential of
liability to clients in accordance with predetermined regulations,
policies and procedures.
- Collects and records required Utilization Management
information for appropriate management of the patients in the units
to which they are assigned.
- Maintains accurate, legible, confidential documents and records
pertaining to medical reviews.
- Facilitates the review process by ensuring the timely delivery
of materials to the appropriate personnel.
- Serves as a resource to Interdisciplinary Patient Care Teams
and physicians for the interpretation of external regulations and
organizational policies and procedures pertaining to the
utilization Management process.
- Communicates nationally recognized criteria as
- Utilizes medical knowledge as an advocate for the patient to
provide pertinent information to third party payors.
- Serves as a liaison to assigned nursing units to facilitate the
Utilization Management process and to ensure the continuity of
- Identifies LOS and/or insurance issues and informs
Interdisciplinary Patient Care Team for response.
- Works with third party payor representatives as an
- Facilitates MD to MD reviews as needed.
- Maintains an effective flow of information between the nursing
units, Social Services, physicians, Medical Records, Business
Office and third party payors to facilitate appropriate lengths of
stay (LOS) and to ensure appropriate reimbursement and
- Identifies, addresses and reports all quality issues to
appropriate parties in a professional manner. MINIMUM
- Graduate of an accredited nursing program.
- Currently licensed as a Registered Nurse in the state of
- Two years of recent health care experience (within the past
five years) and one year of experience in utilization management,
quality improvement, or discharge planning.
- A bachelor's degree in nursing or related health care field
preferred. 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.
Keywords: Emory Healthcare, Atlanta , Utilization Management Analyst RN, PRN, Professions , Atlanta, Georgia
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