Registered Nurse (RN) Acute Care - Central Utilization Mgmt- FT Day

2510 Cobb Hospital, Inc.•Mableton, GA

3d•Onsite

About The Position

The Utilization Management (UM) Nurse conducts medical necessity reviews for a defined patient population, using clinical documentation, screening criteria, and communication with physicians, physician advisors, payers, and the care team. Reviews include new admissions, observation cases, and concurrent reviews, and may be assigned by unit, payer, or patient class. The nurse determines or recommends the most appropriate level of care and helps coordinate safe transitions and timely discharge to appropriate post-discharge care. The UM Nurse obtains timely payer authorization for hospital admissions and days, documents reviews and authorizations in EPIC, and monitors post-discharge/prebill accounts for missing authorizations, differences between length of stay and authorized days, and other discrepancies that could result in denials. The role also communicates with payers to resolve discrepancies, tracks avoidable days, and escalates medical reviews, denials, and documentation issues through established channels. This is a full-time, onsite day-shift position at Cobb Hospital. Medical necessity reviews may be conducted for up to 12 hours per day on any of the seven days of the week.

Requirements

Graduate of an accredited or approved school of nursing.
At least 3 years of clinical practice or experience, with strong clinical knowledge.
Required Registered Nurse license: single-state or RN multi-state compact.
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 impact timely throughput.
Strong computer skills.

Nice To Haves

Bachelor of Science in Nursing (BSN) from an accredited school of nursing.

Responsibilities

Assess the necessity and appropriateness of health services using established screening criteria such as MCG.
Assess payer and insurance coverage requirements and ensure adherence to them.
Identify patient type or admission appropriateness issues and collaborate with physicians or physician advisors to resolve them.
Identify the need for and refer patients to alternative levels of care in a timely manner.
Obtain timely and accurate certification and authorization for hospital admissions and days, provide required information to payers, and document authorizations in EPIC.
Monitor and evaluate ongoing plans of care and conduct timely concurrent reviews using screening criteria and documentation.
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 applicable payer requirements.
Advocate for patients and negotiate or refer for services that may be needed outside their health care coverage.
Support continuous performance-improvement initiatives based on identified opportunities.
Complete accurate, timely chart notes and maintain up-to-date records, including clinical reviews, insurance updates, authorized days, and denied days with denial reasons.
Work post-discharge/prebill accounts to resolve missing authorization numbers, length-of-stay versus authorized-day variances, and other discrepancies.
Evaluate clinical documentation and escalate issues through the established chain of command.
Track avoidable days in the EPIC avoidable-day module and document review activities according to departmental standards.
Complete initial and ongoing competency assessments and required mandatory and population-specific education.
Serve as a preceptor or mentor for other professionals or students.