RN Utilization Management PRN

Wellstar Health System•Roswell, GA

About The Position

The Utilization Management (UM) Nurse conducts medical-necessity reviews for a defined patient population, reviewing new admissions, observation cases, and concurrent reviews. Reviews are performed using MCG/Indicia criteria, medical-record documentation, and communication with physicians, physician advisors, payers, and the care team to recommend the appropriate level of care and support safe transitions of care. The nurse may conduct reviews for up to 12 hours per day, on any of the seven days of the week, and may be assigned to specific units, payers, or patient classes. The UM Nurse gathers clinical information, applies relevant clinical criteria, policies, procedures, and judgment, and shares pertinent information with payers. The role supports timely authorization of hospital admissions and days, accurate documentation in EPIC, and timely discharge to appropriate post-discharge care. It also includes working post-discharge/prebill accounts to resolve missing authorizations, authorized-length-of-stay variances, and other discrepancies that could result in payer denials. The nurse documents review activities and communications, tracks avoidable days in EPIC, and escalates medical-review or denial issues as needed. The position also monitors compliance with payer and Medicare/Medicaid requirements, advocates for patients, participates in performance-improvement initiatives, and completes required competency assessments and education. The nurse may serve as a preceptor or mentor and performs other assigned duties while following Wellstar policies, standards of work, and its code of conduct.

Requirements

Associate degree in Nursing or nursing diploma required; a Bachelor of Science in Nursing is preferred.
Current RN license: single-state RN or RN multi-state compact license.
BLS certification (or an accepted American Red Cross or instructor equivalent).
At least 3 years of experience.
Strong clinical knowledge with clinical practice/experience.

Nice To Haves

Bachelor of Science in Nursing.

Responsibilities

Conduct medical-necessity reviews for new admissions, observation cases, and concurrent reviews using MCG/Indicia criteria and medical-record documentation.
Assess the necessity and appropriateness of health services and identify referrals to alternative levels of care when appropriate.
Determine and document the recommended level of care, applying clinical criteria, policies, procedures, and clinical judgment.
Obtain timely and accurate authorization for hospital admissions and days, provide required information to payers, and document authorizations in EPIC.
Monitor ongoing plans of care and complete concurrent reviews within established standards.
Evaluate managed-care denials and collaborate with attending physicians, physician advisors, and managed-care representatives to seek overturns when appropriate.
Monitor compliance with Medicare, Medicaid, and payer regulations and requirements.
Advocate for patients and negotiate or refer for services that may be needed outside their health-care coverage.
Assess insurance and coverage requirements and identify patient-type or admission-appropriateness issues for resolution with physicians or physician advisors.
Complete accurate and timely chart notes and document clinical reviews, insurance updates, authorized days, and denied days with reasons for denial.
Work post-discharge/prebill accounts to resolve missing authorization numbers, authorized-length-of-stay variances, and other discrepancies before billing.
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 department standards and procedures.
Participate in continuous performance-improvement initiatives and complete required competency assessments and education.
Serve as a preceptor or mentor for other professionals or students, as applicable.
Perform other duties as assigned and comply with Wellstar policies, standards of work, and code of conduct.