Registered Nurse (RN) - Utilization Management - PRN - North Fulton

Wellstar Health System•Roswell, GA

About The Position

The Utilization Management Nurse conducts medical necessity reviews for a defined patient population, using Indicia for Case Management, MCG Indicia, Indicia for Admission Documentation (IAD), and Indicia for Effective Focus (IEF), alongside medical-record documentation and communication with physicians and the care team. Reviews include new admissions, observation cases, and concurrent reviews, and may be conducted for up to 12 hours per day on any of the seven days of the week. The nurse gathers clinical information, applies relevant clinical criteria and professional judgment, recommends the appropriate level of care, and provides pertinent information to payers. The nurse collaborates with providers and other parties throughout the care continuum to support effective care in the appropriate setting, safe transitions, and timely discharge to an appropriate post-discharge level of care. The role includes obtaining timely payer authorization for hospital days, documenting authorizations and review activities in EPIC, and tracking avoidable days. The nurse also reviews post-discharge/prebill accounts for missing authorizations, authorized-length-of-stay variances, and other discrepancies that could result in payer denials; communicates with payers to resolve issues before billing; and escalates medical review requests or denial activity as needed. The position assesses coverage and payer requirements, monitors compliance with Medicare and Medicaid regulations, supports denial reviews with physicians and physician advisors, and advocates for patients when services may be needed outside their coverage. The nurse completes required professional competency and education activities, may serve as a preceptor or mentor, and performs other assigned duties while complying with Wellstar policies, standards of work, and code of conduct.

Requirements

Associate degree or diploma in nursing; a bachelor's degree in nursing is preferred.
Registered Nurse license: single-state RN or RN multi-state compact license.
Basic Life Support certification, including an accepted American Red Cross or instructor equivalent.
At least 3 years of experience.
Strong clinical knowledge with clinical practice or experience.

Nice To Haves

Bachelor's degree in nursing.

Responsibilities

Review new admissions, observation cases, and concurrent reviews for medical necessity and appropriateness of services using established screening criteria.
Determine or recommend the appropriate level of care and identify referrals to alternative levels of care when needed.
Obtain timely and accurate authorization or certification for hospital admissions and days, provide required information to payers, and document authorizations in EPIC.
Monitor patients’ ongoing plans of care and complete timely concurrent reviews using screening criteria.
Review managed-care denials and collaborate with attending physicians, physician advisors, and managed-care representatives to address or overturn denials.
Monitor compliance with Medicare, Medicaid, payer regulations, and coverage requirements.
Advocate for patients and negotiate or refer for services that may be needed outside their health care coverage.
Complete accurate, timely chart notes and documentation of clinical reviews, insurance updates, authorized days, and denied days and reasons.
Work post-discharge/prebill accounts to resolve missing authorization numbers, authorized-length-of-stay variances, and other discrepancies before billing.
Evaluate clinical documentation and escalate issues through the established chain of command.
Track avoidable days in EPIC according to department standard work.
Participate in continuous performance improvement initiatives and complete required competency assessments and education.
Serve as a preceptor or mentor for other professionals or students, as applicable.
Perform other assigned duties and comply with Wellstar policies, standards of work, and code of conduct.