RN Utilization Management - North Fulton - Various Shifts

Wellstar Health System•Roswell, GA

About The Position

The Utilization Management (UM) Nurse conducts medical necessity reviews, up to 12 hours per day, on any of the seven days per week. The nurse reviews new admissions, observation cases, and concurrent reviews for assigned units, payers, and/or patient classes. Reviews use MCG Indicia, Indicia for Admission Documentation (IAD), and Indicia for Effective Focus (IEF), together with medical record documentation, clinical judgment, and communication with physicians and the care team. The UM Nurse gathers clinical information, applies appropriate criteria and payer requirements, recommends the most appropriate level of care, and shares pertinent information with payers. The role supports safe transitions of care, timely discharge to appropriate post-discharge settings, and effective use of healthcare services. It also includes obtaining timely authorization for hospital days, maintaining accurate documentation in EPIC, and resolving pre-bill account discrepancies that could result in payer denials. The nurse communicates with third-party payers, documents actions, escalates medical review requests or denial issues as needed, and tracks avoidable days in EPIC. The nurse assesses the necessity and appropriateness of services, monitors ongoing plans of care, conducts concurrent reviews, evaluates denials, advocates for patients, and collaborates with attending physicians, physician advisors, managed care representatives, and the multidisciplinary team. The role also requires compliance with Medicare/Medicaid and payer regulations, participation in performance improvement, completion of required competency and education, and may include serving as a preceptor or mentor.

Requirements

Associate degree in Nursing or a nursing diploma; a bachelor's degree in Nursing is preferred.
Current RN license: single-state RN or RN compact/multistate license.
At least 3 years of experience.
Strong clinical knowledge with clinical practice or experience.
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 screening criteria and ability to review clinical data and identify variances.
Ability to think critically, analyze information, effect change, and influence timely throughput.
Strong computer skills.

Nice To Haves

Bachelor's degree in Nursing.

Responsibilities

Conduct medical necessity reviews for new admissions, observation cases, and concurrent reviews using established screening criteria, including MCG Indicia.
Assess the necessity and appropriateness of health services and identify needs for alternative levels of care.
Obtain timely and accurate certification or authorization for hospital admissions and days, provide required information to payers, and document authorizations in EPIC.
Monitor ongoing plans of care and complete timely concurrent reviews to determine appropriate level of care.
Evaluate managed-care denials and collaborate with attending physicians, physician advisors, and managed-care representatives to seek resolution or overturn denials.
Monitor compliance with Medicare/Medicaid and payer regulations and ensure information is documented to help prevent disputes and denials.
Advocate for patients and negotiate or refer for services that may be needed outside their healthcare coverage.
Assess insurance and coverage requirements and identify patient-type or admission-appropriateness issues for resolution with physicians or physician advisors.
Complete accurate, timely chart notes and keep records up to date, including clinical reviews, insurance updates, authorized days, and denied days with reasons.
Work post-discharge/pre-bill accounts daily to resolve missing authorization numbers, authorized-length-of-stay variances, and other discrepancies.
Evaluate clinical documentation and escalate issues through the established chain of command.
Track avoidable days accurately in the EPIC avoidable-day module and document review activities.
Identify, participate in, and support continuous performance improvement initiatives.
Complete initial and ongoing competency assessments and required mandatory and population-specific education.
Serve as a preceptor and/or mentor for professionals or students.
Perform other assigned duties and comply with WellStar policies, standards of work, and code of conduct.