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

2510 Cobb Hospital, Inc.•Mableton, GA

20d•Onsite

About The Position

The Utilization Management Nurse Coordinator conducts medical necessity reviews around the clock for assigned patients, payers, units, or patient classes. The nurse reviews new admissions, observation cases, and ongoing cases, applying established clinical screening criteria such as MCG Indicia alongside medical-record documentation, communication with physicians, and clinical judgment to recommend the appropriate level of care. The role shares clinical information with payers, obtains timely authorization for hospital admissions and days, and communicates authorization status to the care team to support safe transitions of care. The nurse monitors ongoing plans of care and conducts concurrent reviews, assesses insurance and coverage requirements, identifies patient-type or admission-appropriateness issues, and collaborates with physicians, physician advisors, and managed-care representatives to address denials and care needs. The role also supports compliance with Medicare, Medicaid, and payer requirements; advocates for patients; and refers or negotiates for services that may fall outside coverage. Responsibilities include maintaining accurate and timely clinical and authorization documentation in EPIC, tracking avoidable days, and resolving post-discharge/prebill account discrepancies such as missing authorization numbers or differences between length of stay and authorized days. The nurse escalates review requests, denials, and documentation concerns through the established chain of command, and participates in competency education, performance improvement, and mentoring or precepting activities. This is a PRN role at Cobb Hospital, with a requirement to 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

At least three years of strong clinical knowledge with clinical practice or experience.
Associate degree in Nursing or a nursing diploma; a Bachelor of Science in Nursing is preferred.
Current Registered Nurse license: single-state RN or RN compact/multistate license.
BLS certification through the American Heart Association or American Red Cross, or BLS Instructor certification.
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 positively impact timely throughput.
Strong computer skills.
Availability to meet the PRN requirement of four shifts per four-week schedule period and 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 reviews of new admissions, observation cases, and concurrent cases using established screening criteria, including MCG Indicia.
Assess the necessity and appropriateness of services and recommend the appropriate level of care using clinical information, documentation, and clinical judgment.
Identify and refer patients for an alternative level of care when appropriate.
Obtain timely certification and authorization for hospital admissions and hospital days, provide required clinical information to payers, and document authorizations in EPIC.
Monitor patients’ ongoing plans of care and conduct timely concurrent reviews.
Assess insurance and coverage requirements and ensure compliance with payer requirements.
Identify issues involving patient type or admission appropriateness and collaborate with physicians or physician advisors to resolve them.
Review managed-care denials and collaborate with attending physicians, physician advisors, and managed-care representatives to seek resolution or overturn denials.
Monitor compliance with Medicare and Medicaid regulations and payer requirements.
Advocate for patients and negotiate or refer for services that may be needed outside their coverage.
Communicate with providers and other parties to facilitate care and treatment and safe transitions of care.
Complete accurate, timely chart notes and maintain up-to-date records, including clinical reviews, insurance updates, authorized days, and denied days with reasons.
Work post-discharge/prebill accounts daily to resolve missing authorization numbers, length-of-stay versus authorized-day variances, and other discrepancies before billing.
Evaluate clinical documentation, escalate issues through the established chain of command, and escalate medical review requests or denial activities to management as needed.
Track avoidable days in the EPIC avoidable-day module and perform timely documentation of review activities.
Identify and support continuous performance-improvement initiatives.
Complete initial and ongoing competency assessments and required mandatory and population-specific education.
Serve as a preceptor or mentor for other professionals or students.
Perform other duties as assigned and comply with WellStar Health System policies, standards of work, and code of conduct.
Work four shifts in each four-week schedule period and one major and one minor holiday per year, or as assigned by departmental rotation.