Registered Nurse (RN) - Utilization Review -Acute Care PT Weekends

Wellstar Health System•Austell, GA

1d•Onsite

About The Position

The Utilization Management (UM) Nurse conducts medical necessity reviews for a defined patient population, using Indicia for Case Management and related clinical criteria. The nurse reviews new admissions, observation cases, and concurrent reviews; gathers clinical information from medical records; and works with physicians, physician advisors, payers, and the care team to determine the appropriate level of care and coordinate safe transitions. The role also identifies opportunities to provide effective care in the appropriate setting and support timely discharge to an appropriate post-discharge level of care. The UM Nurse obtains timely payer authorization for hospital days and documents authorizations and clinical review activities in EPIC. The nurse monitors post-discharge/prebill accounts for missing authorizations, authorized-length-of-stay variances, and other discrepancies that could lead to payer denial. The role includes communicating with payers to resolve discrepancies before billing, escalating medical review requests or denials as needed, tracking avoidable days, and complying with payer and Medicare/Medicaid requirements. This is a part-time weekend role at Cobb Hospital with a day shift. The position may conduct reviews for up to 12 hours per day on any day of the week, depending on assignment.

Requirements

At least 3 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; required upon hire.
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 screening criteria and ability to review clinical data and identify variances.
Critical-thinking and analytical skills, with the ability to effect change and support 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, including MCG/Indicia.
Assess the necessity and appropriateness of services, patient type, admission, and level of care; collaborate with physicians and physician advisors to resolve issues.
Identify the need for and refer patients to alternative levels of care when appropriate.
Obtain timely certification and authorization for admissions and hospital days, provide required clinical information to payers, and document authorizations in EPIC.
Monitor ongoing plans of care and complete timely concurrent reviews with supporting documentation.
Evaluate managed-care denials and collaborate with attending physicians, physician advisors, and payer representatives to seek resolution or overturn denials.
Monitor compliance with Medicare/Medicaid and payer requirements; advocate for patients and negotiate or refer for services outside their coverage when needed.
Coordinate with providers and care teams to support safe transitions and timely discharge to the appropriate post-discharge setting.
Review post-discharge/prebill accounts daily for missing authorization numbers, length-of-stay authorization variances, and other discrepancies; communicate with payers to resolve them before billing.
Document account communications and actions accurately, complete chart notes on time, keep records up to date, and track avoidable days in EPIC.
Evaluate clinical documentation and escalate issues through the established chain of command; escalate medical review requests and denials to management as needed.
Participate in continuous performance-improvement initiatives and complete required competency assessments and education.
Serve as a preceptor or mentor for other professionals or students.
Perform other assigned duties and comply with Wellstar policies, standards of work, and code of conduct.