• Lead and oversee the Clinical Documentation Integrity program across participating practices, ensuring consistency, accuracy, and compliance. • Provide leadership, guidance, and support to CDI Specialists, including education, coaching, and performance oversight. • Develop and implement standardized CDI processes, job aids, and error‑prevention tools to optimize documentation workflows and EMR utilization. • Educate providers and clinical staff on best practices for clinical documentation, coding accuracy, and risk adjustment. • Conduct prospective and retrospective documentation reviews; analyze data to identify trends, gaps, and improvement opportunities. • Collaborate with physicians, coders, population health, and practice leadership to support quality programs and value‑based care initiatives. • Ensure compliance with applicable federal, state, and regulatory requirements related to Medicare coding and documentation. • Lead CDI‑related projects and initiatives aligned with organizational goals and population health strategies. • Gather provider feedback to continuously improve educational content and delivery methods.

• Performs inpatient chart review to determine appropriate DRG assignment and assures appropriate documentation in the chart • Coordinates with physicians, nurses, ancillary staff, and the coders in Health Information Management • Documents findings within Carle CDI software • Assures documentation in the chart represents a true clinical picture of the patient diagnoses • Reviews denials for accurate and complete documentation and develops appeal letter when needed

Overview Be inspired. Be rewarded. Belong. At Emory Healthcare. At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be. We provide: - Comprehensive health benefits that start day 1 - Student Loan Repayment Assistance & Reimbursement Programs - Family-focused benefits - Wellness incentives - Ongoing mentorship, development, leadership programs and... more! Description Job Summary: The Utilization Review (UR) Specialist is a Registered Nurse responsible for conducting thorough medical necessity reviews to assist with determining appropriate patient class designation. The UR Specialist will perform timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with the UR Department workflows/processes, clinical nursing judgement, and when necessary, discussions with the provider team and/or Medical Director of UR. Primary duties and responsibilities: Operational Support: 1. Conducts thorough medical necessity reviews to assist with determining appropriate patient class designation. 2. Performs timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with the UR Department workflows/processes, clinical nursing judgement, and when necessary, discussions with the provider team and/or Medical Director of UR. 3. Performs appropriate and accurate initial, admission (episode day one) and concurrent utilization reviews as guided by InterQual Criteria and UR Department workflows on all observation, inpatient, and extended recovery admissions as required based on Emory Healthcare's Utilization Management Plan and the UR Department¿s processes. 4. Ensures that all InterQual reviews are supported with provider team documentation and/or clinical data. 5. When appropriate, the UR Specialist will utilize the UR Department's Severity of Illness/Intensity of Service template to document the medical necessity of the admission or continued stay. 6. While conducting utilization reviews, will identify any Avoidable Delays and accurately document the delay(s) based on the workflow. 7. Follow the UR Department¿s denial workflows as appropriate. 8. Prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital. Compliance: 1. Will identify and complete Medicare Outpatient Observation Notices (MOON), Medicare Change of Status Notice (MCSN), Condition Code 44s and Medicare Hospital Issued Notices of Non-Coverage (HINNs) for Medicare beneficiaries as appropriate. 2. Ensures compliance with all state of Georgia and Federal regulatory requirements as designated in Emory Healthcare's Utilization Management Plan. 3. Maintains all required annual competencies, metrics, and fully participate and engage in department process improvements. Collaboration: 1. Responsible for timely communication to the provider team and interdisciplinary team as it relates to patient class designation and medical necessity of an admission or continued stay on individual patient basis based on UR Department workflows. 2. In a team effort, the UR Specialist will work closely with the UR Department's Case Management Authorization Specialist IP to ensure that authorized days and patient actual LOS are reconciled to ensure appropriate reimbursement for services provided. 3. Responsible for communicating medical necessity denials for in-house patients to the Medical Director of UR, and when designated to the provider team. 4. Serves as a resource to the provider team, Interdisciplinary Care Team, and patient to explain external UR regulations. 5. Provides effective and efficient proactive communication to internal and external customers. 6. Assists in collaborative efforts with the Case Management Department, Revenue Cycle, Physician Advisors, and other required departments. Additional Responsibilities: 1. Ability to multi-task in a fast-paced environment while efficiently handling multiple priorities and ensuring deadlines are met. 2. Performs other duties and tasks as assigned. Travel: Less than 10% of the time may be required. Work Type: This position is a remote position outside traditional office, often from home or another remote setting. Minimum Qualifications: Education - Associate degree in nursing. Experience - Minimum of 5 years of recent acute hospital experience or a minimum of two years of previous utilization review experience. Licensure - Must have a valid, active unencumbered Registered Nurse license approved by the Georgia Licensing Board. Skills - Must meet all quality and productivity expectations and successfully complete yearly competencies. Preferred Qualifications: Education - Bachelor's degree in Nursing strongly preferred. Certification - Case Management certification preferred. Skills - InterQual Level of Care Criteria experience. Previous utilization review experience strongly preferred. PHYSICAL REQUIREMENTS: Occasional to frequent sitting. Close eye work (computers, typing, reading, writing). ENVIRONMENTAL FACTORS: Remote position. Additional Details 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.

We've made a lot of progress since opening the doors in 1942, but one thing has never changed - our commitment to serve, heal, lead, educate, and innovate. We believe that every award earned, every record broken and every patient helped is because of the dedicated employees who fill our hallways. At Ochsner, whether you work with patients every day or support those who do, you are making a difference and that matters. Come make a difference at Ochsner Health and discover your future today! This job facilitates the improved integrity of medical record documentation. Presents opportunities and educates providers on quality clinical documentation, and serves as a resource for providers to link coding guidelines and medical terminology to improve the accuracy and quality of code assignment in accordance with OHS Operational Guidelines. Performs daily evaluation of medical record documentation to include provider notes, lab results, diagnostic information and treatment plans, and communicates with providers face to face or via query forms to clarify or obtain missing, unclear or conflicting documentation. Demonstrates and understanding of complications, co-morbidities, severity of illness, risk or mortality, case mix index, secondary diagnoses, and the impact of procedures on the final Diagnosis Related Group (DRG).To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties. This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at Ochsner's discretion. Education Required - High School diploma or equivalent Work Experience Required - 3 years experience working with minimal supervision. Certifications Required - Current State of Louisiana Registered Nurse License Basic Life Support (BLS) from the American Heart Association Knowledge Skills and Abilities (KSAs) - Must have computer skills and dexterity required for data entry and retrieval of patient information. - Must be proficient with Windows-style applications and keyboard. - Effective verbal and written communication skills and the ability to present information clearly and professionally to varying levels of individuals throughout the patient care process. - Must have computer skills and dexterity required for data entry and retrieval of information - Must be proficient with Windows-style applications, various software packages specific to role and keyboard - Excellent written and verbal communication skills - Good interpersonal skills Job Duties • Performs medical record review on patient admission and throughout the stay for documentation completeness and accuracy in accordance with the Clinical Documentation Program requirements. • Communicates effectively and appropriately with internal and external customers. • Actively participates as a team member and is accountable for own work responsibilities. • Actively supports and participates in provider/hospital performance improvement initiatives. • Demonstrates commitment to continuous self-development with the CDI role. • Adapts behavior to the specific patient population, including but not limited to: respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style. Other related duties as required. The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time. Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards. Complies with the Ochsner Health System Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns. Ochsner is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status. Physical and Environmental Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible. Mechanical lifting devices (carts, dollies, etc.) or team lifts should be utilized. Must be able to stoop, bend, reach and grab with arms and hands, manual dexterity. Must be able to work a flexible work schedule (e.g. 24/7, weekend, holiday, on call availability). Normal routine involves no exposure to blood, body fluid or tissue, but exposure or potential for exposure may occur. The incumbent works with patients who have known or suspected communicable diseases and may enter isolation rooms. The incumbent has an occupational risk for exposure to all communicable diseases. Are you ready to make a difference? Apply Today! Ochsner Health does not consider an individual an applicant until they have formally applied to the open position on this careers website. Please refer to the job description to determine whether the position you are interested in is remote or on-site. Individuals who reside in and will work from the following areas are not eligible for remote work position: Colorado, California, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, New Jersey, New York, Vermont, Washington, and Washington D.C. Ochsner Health endeavors to make our site accessible to all users. If you would like to contact us regarding the accessibility of our website, or if you need an accommodation to complete the application process, please contact our HR Employee Solution Center at 504-842-4748 (select option 1) or careers@ochsner.org. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications. Ochsner is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to any legally protected class, including protected veterans and individuals with disabilities.