Registered Nurse (RN) Acute Care - Central Utilization Mgmt- FT Day

Wellstar Health System•Austell, GA

8d•Onsite

About The Position

The Utilization Management Nurse conducts medical necessity reviews for a defined patient population, including reviews of new admissions, observation cases, and concurrent cases. The nurse applies MCG/Indicia criteria and other applicable policies and clinical judgment to determine or recommend the appropriate level of care, working with physicians, physician advisors, the care team, and payers. The role supports safe care transitions, timely referral to alternative levels of care, and discharge to appropriate post-discharge settings. The UM Nurse obtains timely payer authorization for hospital admissions and days, shares required clinical information, and documents authorizations and review activity in EPIC. The nurse also monitors post-discharge/prebill accounts for missing authorizations, variances between length of stay and authorized days, and other discrepancies that could lead to denial. Responsibilities include communicating with payers to resolve discrepancies, tracking avoidable days, escalating issues through the appropriate channels, and supporting continuous performance improvement. This is a full-time, onsite day-shift position at Cobb Hospital. The posting notes that the role may conduct reviews for up to 12 hours per day on any of the seven days of the week.

Requirements

Graduate of an accredited or approved school of nursing.
At least 3 years of clinical practice or experience, with strong clinical knowledge.
Required Registered Nurse (Single State) license or RN Multi-state Compact license.
Knowledge of the case management process.
Excellent verbal and written communication skills.
Strong organizational skills.
Ability to build strong, trusting relationships with physicians and the multidisciplinary team.
Knowledge of using screening criteria to review clinical data and identify variances.
Ability to critically think, analyze information, effect change, and positively impact timely throughput.
Strong computer skills.

Nice To Haves

Bachelor of Science in Nursing (BSN) from an accredited school of nursing.

Responsibilities

Assess the necessity and appropriateness of health services using established screening criteria such as MCG.
Assess payer insurance and coverage requirements and ensure adherence to those requirements.
Identify patient-type or admission-appropriateness issues and collaborate with physicians or physician advisors to resolve them.
Identify needs for and refer patients to alternative levels of care in a timely manner.
Obtain timely and accurate certification and authorization for hospital admissions and hospital days, and document authorizations in EPIC.
Provide required clinical information to payers and conduct timely concurrent reviews using screening criteria.
Monitor ongoing plans of care and document clinical reviews and insurance updates, including authorized and denied days and denial reasons.
Evaluate managed-care denials and collaborate with attending physicians, physician advisors, and managed-care representatives to seek resolution or overturn denials.
Monitor compliance with Medicare and Medicaid regulations and applicable payer requirements.
Advocate for patients and negotiate or refer for services that may be needed outside their health-care coverage.
Resolve post-discharge/prebill account discrepancies, including missing authorization numbers and differences between length of stay and authorized days.
Evaluate patient-record documentation, escalate issues through the established chain of command, and communicate with payers to resolve discrepancies before billing.
Document account communications and actions accurately and concisely in accordance with policies and procedures.
Track avoidable days in the EPIC avoidable-day module and complete review documentation accurately and on time.
Identify, participate in, and support continuous performance-improvement initiatives.
Complete initial and ongoing competency assessments and required mandatory and population-specific education.
Serve as a preceptor or mentor for other professionals or students.