Registered Nurse (RN) - Utilization Management – FT/Day - Augusta

Job Summary

As an on-site Hospital Utilization Management (UM) Nurse, you are the primary link between the clinical floor and administrative compliance. 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). Being physically present allows direct influence on the hospital's throughput, length of stay, and reimbursement accuracy.

Key On-Site Responsibilities

• 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 recommend the most appropriate level of care.
• Use criteria like InterQual or MCG to perform on-site concurrent reviews of active patient care.
• Deliver and explain legally required documents in person, such as condition-code 44 or Medicare observation notices (MOON).
• Proactively identify avoidable days and escalate them to the management team to minimize financial loss.

Core Responsibilities and Essential Functions

• Monitors and evaluates patient/client ongoing plan of care and conducts timely 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 representatives to overturn denials.
• Monitors for compliance of Medicare/Medicaid regulations.
• 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.
• Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. InterQual, MCG).
• Assesses insurance and coverage requirements for all payers and ensures adherence to those requirements at all times.
• Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor for resolution.
• Ensures timely identification of need and referral for alternative level of care.
• Completes chart notes accurately and on time per Departmental protocol.
• Ensures all records are up-to-date.
• Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
• Serves as a preceptor and/or mentor for other professionals 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-I-P - Basic Life Support Instructor-Provisional (180 Days) within 90 Days

Required Minimum Experience

Minimum 3 years strong clinical knowledge with clinical practice/experience required.