Registered Nurse (RN) Utilization Management

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Work Shift

Job Summary:

As an on-site Hospital Utilization Management (UM) Nurse, you are the primary link between the clinical floor and administrative compliance. Unlike remote roles, this position relies heavily on real-time, face-to-face interaction with doctors, patients, and interdisciplinary teams to optimize hospital resources.
The on-site UM Nurse is a Registered Nurse (RN) responsible for performing admission and concurrent medical record reviews to ensure patients are in the correct Patient Class (e.g., Inpatient vs. Outpatient with Observation). By being physically present, one is able to directly influence the hospital's throughput, length of stay, and reimbursement accuracy.

Key On-Site Responsibilities

Physician and Clinical Collaboration
o Physician Consultation: Meet in person with attending/admitting providers to discuss cases where documentation does not support medical necessity or the current level of care.
o Medical Provider Liaison: Function as the primary on-site link between the attending/admitting provider and the Physician Advisor for complex medical necessity determinations.

Real-Time Patient Class Decision Support
o Interdisciplinary Huddles: Attend daily bedside rounds or departmental "bed huddles" to provide immediate input on medical necessity and criteria-led care progression.
o ER Throughput Management: Provide consultation as needed on cases being admitted through the Emergency Department to assess new admissions and recommendations for the most appropriate level of care.

Administrative & Financial Compliance
o Medical Necessity Reviews: Use criteria like InterQual or MCG to perform on-site concurrent reviews of active patient care.
o Issuing Official Notices: Deliver and explain legally required documents in person, such as condition-code 44 or Medicare observation notices (MOON).
o Denial Prevention: Proactively identify "avoidable days "hospital days that do not meet clinical criteria and escalate them to the management team to minimize financial loss.

Core Responsibilities and Essential Functions:

Utilization Management
* Monitors and evaluates patient/clients ongoing plan of care and conducts timely initial and concurrent reviews based on set standards, utilizing screening criteria to monitor care progression with documentation.
* Monitors and evaluates the appropriateness of managed care denials and collaborates with attending physician, physician advisors and managed care representative to overturn denials.
* Monitors for compliance of Medicare/Medicaid regulations
* Meet in person with attending/admitting providers to discuss cases where documentation does not support medical necessity or the current level of care.
* Function as the primary on-site link between the attending/admitting provider and the physician advisor for complex medical necessity determinations.
* Attend daily bedside rounds or departmental "bed huddles" to provide immediate input on medical necessity and criteria-led care progression.
* Provide consultation as needed on cases being admitted through the Emergency Department to assess new admissions and recommendations for the most appropriate level of care.
* Identifies, participates, and supports continuous performance improvement initiatives based on identified opportunities.
* Ensures appropriate compliance with payer regulations and that all information is well documented to prevent payer disputes and denials.

Assessment
* Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG)
* Assesses insurance and coverage requirements for all payers and ensure adherence to those requirements at all time.
* Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor for resolution.

Documentation and Post Discharge
* Completes chart notes accurately and on time per Departmental protocol.
* Ensures all records are up-to-date.
* Ensures timely and accurate documentation of clinical reviews and insurance updates as required by payor including authorized days and denied days with reason for denial
* Works post-discharge/prebill accounts efficiently and effectively daily, to resolve accounts with no auth numbers, ALOS vs. authorized days or other discrepancies.
* Evaluates clinical documentation in patient records and escalates issues through the established chain of command.
* Proactively identify "avoidable days" hospital days that do not meet clinical criteria and escalate them to the management team to minimize financial loss.

Professional Development and Initiative
* Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
* Serves as a preceptor and/or or mentor for other professional and/or students
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• Associates Nursing or Diploma (Nurse) Nursing or Bachelors Nursing-Preferred

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact

• BLS - Basic Life Support or

• BLS-I - Basic Life Support - Instructor or

• ARC-BLS - Amer Red Cross Basic Life Support or

• BLS-P - Basic Life Support-Provisional (30 Days) within 90 Days

Additional License(s) and Certification(s):

• BLS within 90 Days Required

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Required Minimum Experience:

• Minimum 3 years Strong clinical knowledge with clinical practice/experience Required

Required Minimum Skills:

• Knowledge of Case Management process.

• Excellent verbal and written communication skills.

• Strong organizational skills. Medium

• Ability to build strong and trusting relationships with physicians and the multidisciplinary team. Medium

• Knowledgeable with utilizing screening criteria in review of clinical data and identifying variance. High

• Ability to critically think and analyze information, effect change, and effectively impact timely throughput. Medium

• Strong computer skills required. Medium

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.