RN Utilization Management Part Time

Wellstar Health System•Douglasville, GA

23h•Onsite

About The Position

The on-site Hospital Utilization Management Nurse is a Registered Nurse who performs admission and concurrent medical record reviews to ensure patients are assigned the appropriate patient class and level of care. The role relies on real-time, in-person interaction with physicians, patients, and interdisciplinary teams to support medical necessity, care progression, hospital throughput, length of stay, and reimbursement accuracy. The nurse reviews clinical records using screening criteria, assesses payer and coverage requirements, monitors compliance with Medicare and Medicaid regulations, and works with attending physicians, physician advisors, and managed care representatives to resolve medical necessity questions and denials. The role also supports emergency department admission decisions, attends bedside rounds or bed huddles, issues required patient notices, and identifies avoidable days or documentation concerns. The position includes timely and accurate documentation of clinical reviews and insurance updates, post-discharge and pre-bill account follow-up, participation in performance improvement initiatives, completion of required education and competency assessments, and serving as a preceptor or mentor when needed. The employee must comply with Wellstar Health System policies, standards of work, and code of conduct.

Requirements

Associate degree in Nursing or a Nursing diploma required; Bachelor of Science in Nursing preferred.
Current Registered Nurse license: single-state RN or multistate compact RN.
Basic Life Support certification required; accepted options include BLS, BLS Instructor, or American Red Cross BLS.
At least 3 years of experience.
Strong clinical knowledge with clinical practice 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.

Responsibilities

Monitor and evaluate patients’ ongoing plans of care and conduct timely initial and concurrent reviews using screening criteria and documented care-progression standards.
Review managed care denials and collaborate with attending physicians, physician advisors, and managed care representatives to seek reversal of denials.
Monitor compliance with Medicare and Medicaid regulations and applicable payer requirements.
Meet in person with attending and admitting providers about cases where documentation does not support medical necessity or the current level of care.
Serve as the on-site liaison between attending or admitting providers and the physician advisor for complex medical necessity determinations.
Attend daily bedside rounds or departmental bed huddles and provide input on medical necessity and criteria-led care progression.
Consult on Emergency Department admissions and recommend an appropriate level of care.
Identify and support continuous performance improvement initiatives.
Ensure payer compliance and maintain documentation to help prevent payer disputes and denials.
Assess the necessity and appropriateness of health services using established screening criteria, such as MCG.
Assess insurance and coverage requirements for all payers and ensure adherence to those requirements.
Identify patient-type or admission-appropriateness issues and collaborate with a physician or physician advisor to resolve them.
Complete chart notes accurately and on time, and keep records up to date.
Document clinical reviews and insurance updates, including authorized and denied days and denial reasons, in accordance with payer requirements.
Work post-discharge and pre-bill accounts daily to resolve missing authorization numbers, average length-of-stay versus authorized-day discrepancies, and other issues.
Evaluate clinical documentation and escalate issues through the established chain of command.
Identify avoidable days and escalate them to management to minimize financial loss.
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.
Perform other duties as assigned and comply with Wellstar Health System policies, standards of work, and code of conduct.
Deliver and explain required notices in person, including condition-code 44 and Medicare observation notices (MOON).