Registered Nurse (RN) -Acute Care - Uitilization Managment PRN Days

Wellstar Health System•Austell, GA

8d•Onsite

About The Position

The Utilization Management Nurse Coordinator conducts medical necessity reviews for admissions, observation cases, and concurrent reviews. Using MCG Indicia and patient-record documentation, the nurse applies clinical criteria, policies, procedures, and clinical judgment to recommend the appropriate level of care and provide supporting information to payers. The role communicates with physicians, physician advisors, payers, the care team, and other parties to coordinate care and safe transitions. The nurse obtains timely authorization for hospital admissions and days, documents authorization and review activity in EPIC, and monitors post-discharge/prebill accounts for missing authorizations, authorized-length-of-stay variances, and other discrepancies that could result in payer denials. The role works with third-party payers to resolve discrepancies before billing, tracks avoidable days, escalates review or denial issues as appropriate, and maintains accurate documentation in accordance with policies and procedures. This is a PRN day position at Wellstar Cobb Hospital, scheduled for three shifts every 28 days. One weekend or holiday shift may be required.

Requirements

At least 3 years of clinical practice or experience, with strong clinical knowledge.
Current RN license: single-state or RN compact multi-state.
BLS certification through an accepted provider: Basic Life Support, American Red Cross Basic Life Support, or Basic Life Support Instructor.
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 think critically, analyze information, effect change, and support timely throughput.
Strong computer skills.

Nice To Haves

Bachelor of Science in Nursing (preferred).

Responsibilities

Conduct medical necessity assessments and utilization reviews for new admissions, observation cases, and concurrent reviews using established criteria such as MCG Indicia.
Determine or recommend the appropriate level of care and identify the need for referral to an alternative level of care.
Obtain timely and accurate certification and authorization for hospital admissions and days, and document authorizations in EPIC.
Provide clinical information to payers and communicate authorization status to the care team.
Monitor ongoing plans of care and complete concurrent reviews according to standards and payer requirements.
Collaborate with attending physicians, physician advisors, and managed care representatives to address and overturn inappropriate denials.
Monitor compliance with Medicare, Medicaid, payer regulations, and insurance coverage requirements.
Advocate for patients and negotiate or refer for services that may be needed outside their health care coverage.
Work post-discharge and prebill accounts to resolve missing authorization numbers, length-of-stay authorization variances, and other account discrepancies.
Communicate with third-party payers to resolve discrepancies before billing and escalate issues through the established chain of command as needed.
Accurately document clinical reviews, insurance updates, authorized and denied days, communications, and actions taken.
Track avoidable days in the EPIC avoidable day module and maintain current records.
Participate in continuous performance-improvement initiatives.
Complete required competency assessments and education, and 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.