RN Central Utilization Mgmt

Wellstar Health System•Austell, GA

8d•Onsite

About The Position

The Utilization Management Nurse conducts medical necessity reviews for a defined patient population, using Indicia for Case Management and established clinical criteria. The nurse reviews new admissions, observation cases, and concurrent cases, and may be assigned to specific units, payers, or patient classes. Reviews involve examining medical records, communicating with physicians and physician advisors, and collaborating with the care team to coordinate safe transitions of care. The nurse gathers clinical information and applies appropriate criteria, policies, procedures, and clinical judgment to recommend the most appropriate level of care. The role includes sharing pertinent clinical information with payers, facilitating care and treatment across the continuum, identifying opportunities for effective services and timely discharge, and obtaining timely authorization for hospital days. The nurse documents reviews and authorizations in EPIC and works post-discharge/prebill accounts to resolve missing authorizations, authorized-day variances, and other discrepancies that may lead to payer denials. This is a full-time, day-shift, onsite 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.
Required registered nurse license: single-state or RN multi-state compact license.
At least 3 years of clinical practice or experience, with strong clinical knowledge.
Knowledge of the case management process.
Excellent verbal and written communication skills.
Strong organizational skills.
Ability to build trusting relationships with physicians and the multidisciplinary team.
Ability to use screening criteria to review clinical data and identify variances.
Critical-thinking and analytical skills, ability to effect change, and ability to support timely patient throughput.
Strong computer skills.

Nice To Haves

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

Responsibilities

Initiate assessments of the necessity and appropriateness of health services using established screening criteria such as MCG.
Assess payer insurance and coverage requirements and ensure adherence to those requirements.
Identify patient-type or admission-appropriateness issues and collaborate with physicians or physician advisors to resolve them.
Identify the need for and make timely referrals to alternative levels of care.
Obtain timely and accurate certification and authorization for hospital admissions and hospital days, and document authorizations in EPIC.
Provide required information to payers in a timely manner and obtain authorization for covered days.
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 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 and timely chart notes and maintain current records, including clinical reviews, insurance updates, authorized days, and denied days with denial reasons.
Work post-discharge/prebill accounts daily to resolve missing authorization numbers, authorized-day variances, and other discrepancies; escalate issues through the established chain of command.
Track avoidable days accurately in EPIC and document review activities according to department standards and procedures.
Complete initial and ongoing competency assessments and required mandatory and population-specific education.
Serve as a preceptor or mentor for other professionals and/or students.