Registered Nurse (RN) - Utilization Review -Acute Care PRN Days

2510 Cobb Hospital, Inc.•Mableton, GA

20d•Onsite

About The Position

The Utilization Management Nurse Coordinator conducts medical necessity reviews, using MCG Indicia and clinical records to determine and recommend the most appropriate level of care. The nurse reviews new admissions, observation cases, and concurrent reviews for assigned payers, units, or patient classes, and shares supporting clinical information with payers and authorization status with the care team to support safe transitions of care. The role obtains timely authorization for hospital admissions and days, documents authorizations and review activity in EPIC, and monitors post-discharge prebill accounts for missing authorizations, authorized-length-of-stay variances, and other issues that could result in payer denials. The nurse communicates with payers to resolve discrepancies, collaborates with providers and physician advisors on admission status and denials, and escalates review requests or denial issues through the appropriate channels. The position also evaluates coverage and payer requirements, monitors compliance with Medicare and Medicaid regulations, advocates for patients, tracks avoidable days, and participates in performance-improvement initiatives. The nurse completes required competency assessments and education and may serve as a preceptor or mentor. This is a PRN day-shift role at Cobb Hospital. PRN staff must work four shifts in each four-week schedule period and one major and one minor holiday per year, or as assigned by departmental rotation.

Requirements

Minimum of 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 multi-state license.
BLS certification through an accepted provider or equivalent listed credential.
Knowledge of the case management process.
Excellent verbal and written communication skills.
Strong organizational skills.
Ability to build trusting relationships with physicians and the multidisciplinary team.
Knowledge of screening criteria and ability to review clinical data and identify variances.
Ability to think critically, analyze information, effect change, and positively impact timely throughput.
Strong computer skills.
PRN schedule requirement: four shifts in each four-week schedule period.
Work one major and one minor holiday per year, or as assigned by departmental rotation.

Nice To Haves

Bachelor of Science in Nursing.

Responsibilities

Conduct medical necessity and utilization reviews for new admissions, observation cases, and concurrent reviews using established criteria such as MCG Indicia.
Determine and recommend appropriate level of care, including identifying and referring patients for an alternative level of care when appropriate.
Obtain timely certification and authorization for hospital admissions and hospital days, and provide required clinical information to payers.
Document authorizations, clinical reviews, insurance updates, and communications accurately and promptly in EPIC and other appropriate records.
Monitor ongoing plans of care and conduct concurrent reviews according to established standards.
Review managed-care denials and collaborate with attending physicians, physician advisors, and managed-care representatives to address or overturn them.
Assess insurance coverage and payer requirements and identify patient-type or admission-appropriateness issues for resolution with physicians or physician advisors.
Monitor compliance with Medicare and Medicaid requirements and payer regulations.
Advocate for patients and negotiate or refer for services that may be needed outside their health coverage.
Work post-discharge, prebill accounts to resolve missing authorization numbers, authorized-length-of-stay variances, and other discrepancies that could result in denials.
Evaluate patient-record documentation and escalate issues through the established chain of command.
Track avoidable days in the EPIC avoidable day module.
Participate in and support continuous performance-improvement initiatives.
Complete initial and ongoing competency assessments, mandatory education, and population-specific education.
Serve as a preceptor or mentor for other professionals or students.
Perform other duties as assigned and comply with Wellstar policies, standards of work, and code of conduct.