RN Central Utilization Mgmt

2510 Cobb Hospital, Inc.•Mableton, GA

3d•Onsite

About The Position

The Utilization Management Nurse conducts medical necessity reviews for a defined patient population, using clinical documentation, established screening criteria, and clinical judgment to recommend the most appropriate level of care. The role reviews new admissions, observation cases, and concurrent reviews, and collaborates with physicians, physician advisors, the care team, and payers to coordinate care and safe transitions. Reviews use MCG Indicia, Indicia for Admission Documentation (IAD), and Indicia for Effective Focus (IEF), along with medical records and payer requirements. The UM Nurse obtains timely authorization for hospital admissions and days, communicates relevant clinical information to payers, documents authorizations and review activity in EPIC, and works post-discharge/prebill accounts to resolve missing authorizations, length-of-stay variances, and other discrepancies that could lead to denials. The nurse monitors ongoing care, supports timely discharge to appropriate post-discharge settings, tracks avoidable days, escalates issues through the appropriate channels, and participates in performance improvement and professional development activities. This is a full-time, onsite, day-shift position at Cobb Hospital. The posting notes 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 multistate compact, as applicable.
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 (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 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 and refer patients for alternative levels of care when appropriate.
Obtain timely and accurate certification and authorization for hospital admissions and hospital days, and provide required information to payers.
Document authorizations in EPIC and monitor and document concurrent reviews and ongoing plans of care.
Monitor 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.
Support continuous performance-improvement initiatives based on identified opportunities.
Complete accurate and timely chart notes and clinical-review documentation, including authorized and denied days and 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 according to department 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.