Remote Utilization Review Nurse Jobs in Decatur, GA

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The Case Management Authorization Specialist IP (CMAS) has a general understanding of insurance requirements as it relates to insurance verification, notification, authorization and collaboration.

This role functions with minimal oversight and guidance in the Care Management Inpatient Department or Utilization Management Department with distinct responsibilities.

RESPONSIBILITIES:

Care Management Inpatient Department:

• Assists the Care Management Inpatient team to timely transition patients into post-acute services within the allotted amount of reimbursable hospital days, as determined by the clinical authorization obtained.
• Submits referrals for securing post-acute care services as directed, which may include Home Health, Durable Medical Equipment, Subacute Rehabilitation, Inpatient Rehabilitation Facility, Long-Term Acute Care, Hospice, or Long-Term Care.
• Prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital.
• Ensures proper use of Care Management Systems and display adherence with workflows, which guide all responsibilities.

Utilization Management Department:

• Verify insurance eligibility and submit notice of admission (NOA) for inpatient and observation admissions to the identified primary and secondary insurances based on the payer's notification requirements and UR Department processes.
• Verify completion of automated NOAs for appropriate insurances, and if necessary, will resubmit manually.
• Submit appropriate admission and continued stay clinical documentation supporting services or care provided to insurances without access to Emory's Electronic Health Record based on payer's preferred method and reimbursement methodology.
• Secures reimbursement by confirming insurance authorization determination for the inpatient or observation admission through appropriate and required communication methods.
• Will add approved bed days to Emory's Electronic Health Record as appropriate based on authorization and reconcile authorized versus actual days to secure reimbursement for provided care.
• Prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital.
• Display adherence with department processes, which guide all responsibilities.

COMPLIANCE:

Care Management Inpatient Department:

• Ensure regulatory requirements are met as it relates to the delivery of Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), Medicare Change of Status Notice (MCSN), and Medicare Hospital Issued Notices of Non-Coverage (HINNs) for Medicare beneficiaries as appropriate.
• Maintains all required annual competencies, metrics, and fully participate and engage in department process improvements.

Utilization Management Department:

• Maintains all required annual competencies, metrics, and fully participate and engage in department process improvements.

COLLABORATION:

Care Management Inpatient Department:

• Collaborates with insurance to initiate/request authorizations for post-acute care.
• Provides effective and efficient proactive communication to internal and external customers.
• Assists in collaborative efforts with the Utilization Management Department, Revenue Cycle, Care Management Medical Directors, and other required departments.

Utilization Management:

• Follow the UR DepartmentAs peer-to-peer workflow as appropriate.
• Will inform the Patient Access Department and UM leadership of any discrepancies identified related to coordination of benefits and/or coverage as it relates to ineligible coverage, non-covered services or out of network status.
• Assists in collaborative efforts with the Care Management Department, Revenue Cycle, Utilization Review Medical Directors, and other required departments.

ADDITIONAL RESPONSIBILITIES:

• Ability to multi-task in a fast-paced environment while efficiently handling multiple priorities and ensuring deadlines are met.
• May specialize in certain payors but overall is an insurance generalist within the department.
• Assists with providing technical and clerical support, as directed.
• Performs other duties and tasks as assigned.

TRAVEL:

• Less than 10% of the time may be required.

WORK TYPE:

• Care Management IP Department: On-site.
• Utilization Management Department: This position is a remote position outside traditional office, often from home or another remote setting.

MINIMUM QUALIFICATIONS:

• Education - High School diploma or equivalent.
• Experience - At least two years of experience in a healthcare setting is required.

PREFERRED QUALIFICATIONS:

• Education - Associate or Bachelor's degree preferred.
• Experience - Two years of insurance verification, authorization, or related work preferred.

PHYSICAL REQUIREMENTS: (Medium): 20-50 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 50 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, and environmental conditions may vary depending on assigned work area and work tasks.

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.