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

Wellstar Health System • Austell, GA

1d • Onsite

About The Position

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

This role is PRN Days - at Cobb Hospital.

Requirements

• Minimum 3 years Strong clinical knowledge with clinical practice/experience.
• RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact
• BLS - Basic Life Support or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor
• Knowledge of Case Management process.
• Excellent verbal and written communication skills.
• Strong organizational skills.
• Ability to build strong and trusting relationships with physicians and the multidisciplinary team.
• Knowledgeable with utilizing screening criteria in review of clinical data and identifying variance.
• Ability to critically think and analyze information, effect change, and effectively impact timely throughput.
• Strong computer skills required.

Nice To Haves

• Bachelors Nursing

Responsibilities

• Conducting medical necessity reviews 24 hours per day, 7 days per week.
• Utilizing mcg Indicia for clinical reviews and sharing clinical information with payers.
• Sharing authorization status with the care team for safe transitions of care.
• Performing utilization review on all new admissions, observation cases, and concurrent reviews.
• Applying appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to complete determination/recommendation for the most appropriate level of care status.
• Providing supporting clinical information to payers.
• Communicating with providers and other parties to facilitate care/treatment.
• Obtaining timely authorization of all ALOS days from payers and ensuring documentation in EPIC for timely billing.
• Monitoring post discharge, prebill accounts for discrepancies that may result in denial.
• Communicating with third party payors to resolve discrepancies prior to billing.
• Documenting all communications and actions taken on the account.
• Escalating medical review request and/or denial activities to management.
• Working post discharge, prebill accounts efficiently and effectively to resolve accounts with missing authorization numbers, ALOS vs. authorized days or other discrepancies.
• Evaluating clinical documentation in patient records and escalating issues.
• Tracking avoidable days accurately in the avoidable day module in EPIC.
• Performing accurate and timely documentation of all review activities.
• Initiating assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG).
• Ensuring timely identification of need and referral for alternative level of care.
• Responsible for timely and accurate certification/authorization of hospital admissions and hospital days.
• Provides required information to payors in a timely fashion and obtains appropriate authorization for all days.
• Monitors and evaluates patient/clients ongoing plan of care and conducts timely concurrent reviews based on set standards, utilizing screening criteria to determine level of care with documentation.
• Monitors and evaluates the appropriateness of managed care denials and collaborates with attending physician, physician advisors and managed care representative to overturn denials.
• Monitors for compliance of Medicare/Medicaid regulations.
• Advocates for patient and negotiates and refers for services that maybe required outside of patients health care coverage.
• Identifies, participates, and supports continuous performance improvement initiatives based on identified opportunities.
• Ensures appropriate compliance with payer regulations and that all information is well documented to prevent payer disputes and denials.
• Assesses insurance and coverage requirements for all payers and ensure adherence to those requirements at all time.
• Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor for resolution.
• Completes chart notes accurately and on time per Departmental protocol.
• Ensures all records are up-to-date.
• Ensures timely and accurate documentation of clinical reviews and insurance updates as required by payor including authorized days and denied days with reason for denial.
• Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
• Serves as a preceptor and/or or mentor for other professional and/or students.
• Performs other duties as assigned.
• Complies with all WellStar Health System policies, standards of work, and code of conduct.

Benefits

• PRN Requirements: four (4) shifts in a four-week schedule period
• Work one (1) major and one (1) minor holiday per year, or as otherwise assigned by departmental rotation.

What This Job Offers

• Career Level: Mid Level
• Education Level: Associate degree