Utilization Review Nurse Jobs in Decatur, GA (NOW HIRING)

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Work Location: Atlanta, GA

The Director of Utilization Management plays a pivotal role in our healthcare system by overseeing and optimizing the utilization of resources and services across our organization.

Utilization management includes, but is not limited to, analyzing entrance into care environments from multiple perspectives including payors, healthcare system, patient/family, and providers; ensuring appropriate and high quality care in the most appropriate setting and most appropriate cost; analyzing the effectiveness of treatment before, during and after care delivery; and, developing relationships with and educating payors, healthcare executives, patients and families, and providers.

This position is responsible for developing and implementing utilization management strategies that align with our commitment to high quality and safe care, outstanding patient experience, cost-effectiveness, and regulatory compliance.

Strategic Planning:

• Develop and execute utilization management strategies that align with the organization's mission, vision, and values
• Collaborate with senior leadership to establish short-term and long-term objectives

Team Leadership:

• Lead and manage a team of utilization management professionals, including nurses, case managers, and analysts, to ensure efficient and effective utilization of resources

Utilization Review:

• Implement systemwide utilization review processes and policies to assess the appropriateness of healthcare services, medical treatments, and length of stay
• Make recommendations for adjustments as needed

Quality and Process Improvement:

• Collaborate with the Office of Quality to continuously improve care delivery processes and outcomes
• Ensure adherence to quality standards and regulations

Operational Efficiency:

• Develop and monitor utilization management programs that control internal and external costs without compromising the quality of care, making data-driven decisions to reduce unnecessary resource utilization

Data Analysis:

• Utilize data and analytics to identify trends, opportunities for improvement, and areas where resource utilization can be optimized
• Educate direct reports in utilization of data and analytics to drive performance improvement
• Regularly report findings and recommendations to the executive team

Regulatory Compliance:

• Stay informed about healthcare regulations and reimbursement policies, ensuring that the organization complies with all relevant laws and guidelines
• Ensure that each direct report is aware of these and practices the same

Interdepartmental Collaboration:

• Foster effective communication and collaboration with various departments, including medical staff, finance, nursing, and administration, to ensure seamless utilization management

Education and Training:

• Provide training and education to staff members regarding utilization management processes, policies, and best practices

Reporting: Prepare and present regular reports to senior leadership on utilization management initiatives, outcomes, and performance indicators

Required Minimum Qualifications:

• Masters degree in healthcare management, nursing, or a related field
• Valid healthcare administration license or certification (e.g., Registered Nurse, Certified Professional in Healthcare Management)
• Proven leadership experience in utilization management or a related field within the healthcare industry
• In-depth knowledge of healthcare regulations, insurance, and reimbursement policies
• Strong analytical, problem-solving, and data-driven decision-making skills
• Excellent interpersonal, communication, and presentation skills
• Ability to lead, motivate, and develop a high-performing team
• Strong project management, process improvement, and organizational skills

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.