Registered Nurse (RN) - Utilization Review - Acute Care PRN Days
Wellstar Health System
Summary
The Utilization Management Nurse (UM) Coordinator is responsible for conducting medical necessity reviews 24 hours per day, 7 days per week. Utilizing MCG Indicia, clinical reviews are performed and clinical information shared with payers and authorization status shared with the care team on the coordination of safe transitions of care for a defined patient population.
Job description
Core Responsibilities and Essential Functions
Utilization Management
- Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG).
- Ensures timely identification of need and referral for alternative level of care.
- Responsible for timely and accurate certification/authorization of hospital admissions and hospital days.
- Provides required information to payors in a timely fashion and obtains appropriate authorization for all days. Ensures authorizations are documented in EPIC in a timely manner.
- Monitors and evaluates patient/clients ongoing plan of care and conducts timely concurrent reviews based on set standards, utilizing screening criteria to determine level of care 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.
- Advocates for patient and negotiates and refers for services that may be required outside of patient's health care coverage.
- 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 times.
- 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.
Professional Development and Initiative
- Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
- Serves as a preceptor and/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.
Requirements
- Associates Nursing or Diploma (Nurse) Nursing or Bachelors Nursing-Preferred
- RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact
- BLS - Basic Life Support or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor
- Minimum 3 years Strong clinical knowledge with clinical practice/experience
- Knowledge of Case Management process
- Excellent verbal and written communication skills
- Strong organizational skills
- Ability to build strong and trusting relationships with physicians and the multidisciplinary team
- Knowledgeable with utilizing screening criteria in review of clinical data and identifying variance
- Ability to critically think and analyze information, effect change, and effectively impact timely throughput
- Strong computer skills required
Company overview
Wellstar Health System is one of Georgia's largest and most comprehensive integrated healthcare systems, founded in 1993 and headquartered in Marietta, Georgia. As a non-profit health system, Wellstar operates with a mission to enhance the health and well-being of every person it serves through its PeopleCare approach. The system employs approximately 29,469 to 33,000 team members across multiple hospitals, health parks, medical offices, outpatient centers, pediatric centers, nursing facilities, and hospice and home care services. Wellstar is nationally recognized for operating Georgia's largest integrated trauma network and features the second-largest Emergency Department in the United States. The organization provides more than $1 billion annually in charity care and community programs, demonstrating its commitment to community health. Wellstar has earned numerous accolades including recognition on Fortune's 100 Best Companies to Work For, Best Workplaces in Health Care, and PEOPLE Companies that Care lists. The system embraces innovation through its venture firm Catalyst by Wellstar, which nurtures early-stage healthcare companies, and maintains academic partnerships with institutions like the Medical College of Georgia for caregiver training. With specialties spanning cardiovascular care, oncology, women's health, pediatrics, musculoskeletal services, and numerous other medical disciplines, Wellstar delivers comprehensive healthcare across all stages of life.