Registered Nurse (RN) - Utilization Review -Acute Care PT Weekends (Sat/Sun 7am-7pm)

Wellstar Health System•Austell, GA

6d•Onsite

About The Position

The Utilization Management (UM) Nurse conducts medical necessity reviews for a defined patient population, reviewing new admissions, observation cases, and concurrent reviews. The nurse applies clinical screening criteria, including MCG Indicia, alongside medical record documentation and communication with physicians and physician advisors to determine or recommend the appropriate level of care. The role collaborates with providers and the care team to coordinate safe transitions, identify appropriate settings for care, and support timely discharge to the appropriate post-discharge level of care. The UM Nurse gathers clinical information, communicates pertinent information to payers, and obtains timely authorization for hospital admissions and days of care. The nurse documents reviews and authorizations in EPIC, monitors post-discharge/prebill accounts for missing authorizations and other discrepancies, and works with third-party payors to resolve issues before billing. The role also tracks avoidable days, escalates medical review requests and denial activities as needed, and supports compliance with payer requirements and Medicare/Medicaid regulations. This is a part-time weekend position at Cobb Hospital, scheduled every Saturday and Sunday from 7 a.m. to 7 p.m. The position requires a minimum of three years of clinical practice or experience and strong clinical knowledge.

Requirements

Minimum three years of clinical practice or experience, with strong clinical knowledge.
Associate degree in Nursing or nursing diploma; a Bachelor of Science in Nursing is preferred.
Current Registered Nurse license: single-state RN or RN compact/multistate 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 impact timely throughput.
Strong computer skills.

Nice To Haves

Bachelor of Science in Nursing.

Responsibilities

Conduct medical necessity reviews for new admissions, observation cases, and concurrent reviews using established screening criteria such as MCG Indicia.
Assess the necessity and appropriateness of health services and identify the need for referral to an alternative level of care.
Determine or recommend the appropriate level of care based on clinical information, medical records, and clinical judgment.
Obtain timely and accurate certification and authorization for hospital admissions and days of care, and document authorizations in EPIC.
Provide required clinical information to payors and communicate with providers, physicians, physician advisors, care teams, and managed care representatives.
Monitor ongoing plans of care and complete timely concurrent reviews using screening criteria.
Monitor managed care denials and collaborate with physicians, physician advisors, and managed care representatives to address or overturn denials.
Monitor compliance with Medicare and Medicaid regulations and payer requirements.
Advocate for patients and negotiate or refer for services that may be required outside of their health care coverage.
Assess insurance and coverage requirements for all payers and ensure adherence to those requirements.
Identify issues related to patient type or admission appropriateness and collaborate with physicians or physician advisors to resolve them.
Complete accurate, timely chart notes and clinical review documentation, including insurance updates, authorized days, and denied days with reasons.
Work post-discharge/prebill accounts to resolve missing authorization numbers, length-of-stay versus authorized-day variances, and other account discrepancies.
Evaluate clinical documentation, escalate issues through the established chain of command, and escalate medical review requests or denial activities to management as needed.
Track avoidable days accurately in the EPIC avoidable day module and document review activities in accordance with departmental standards.
Participate in continuous performance improvement initiatives based on identified opportunities.
Complete initial and ongoing professional competency assessments and required mandatory and population-specific education.
Serve as a preceptor or mentor for other professionals or students.
Comply with Wellstar Health System policies, standards of work, and code of conduct, and perform other duties as assigned.