Care Management RN - PRN

Wellstar Health Systems, Inc.; Austell (GA); On-site; USD 55,000 - 69,000; Part time

Job summary

Wellstar Health Systems, Inc. seeks a PRN Utilization Management Nurse (UM) to conduct medical necessity reviews and coordinate with payers and care teams. This on-site role at Cobb Hospital requires coordinating safe transitions of care, daily reviews, and timely authorizations.

Strong nursing background and EPIC experience are essential. The UM Nurse will document interactions, monitor ALOS, and collaborate with physicians to overturn denials when appropriate.

Qualifications

• RN license and nursing degree required.
• Strong case management and clinical documentation skills.
• Proficient computer skills and experience with EPIC and clinical tools.

Responsibilities

• Perform medical necessity reviews 24/7 and coordinate with payers.
• Document communications and authorization status in the medical record and EPIC.
• Escalate and resolve denials; collaborate with physicians and care teams.
• Assist in patient transitions and ensure timely authorizations for hospital admissions and days.

Skills

Case management knowledge

Computer skills

Physician communication

Education

RN license

Nursing degree

Tools

EPIC EHR

mcg Indicia

Job description

A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Work Shift

This Utilization Management Nurse (UM) is PRN Days. 3 shifts every 28 days. (1 Weekend or Holiday may be required.) Onsite at our Cobb Hospital:

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. The Utilization Management Nurse will perform utilization review every day by looking at all new admissions, all observation cases and concurrent reviews. They will be assigned to specific payer(s)/and or units/and or patient class. All clinical reviews will be performed, utilizing mcg Indicia when specified, in conjunction with medical records documentation communication with physicians and physician's advisors. The UM nurse will gather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to complete the determination/recommendation for the most appropriate level of care status and provide supporting clinical information to the payers. Along the continuum of care, communicates with providers and other parties to facilitate care/treatment. Utilization Management Nurse will obtain timely authorization of all ALOS days from payers and ensure this is documented in the appropriate place in EPIC to enable timely billing. Will monitor post discharge, prebill accounts that do not have an authorization on file, ALOS versus days authorized variances, and/or other account discrepancies identified that will result in the account being denied by the payor that require clinical expertise. The UM Nurse will communicate with third party payors to resolve discrepancies prior to billing. Accurately and concisely documents all communications and action taken on the account in accordance with policies and procedures. Escalate medical review request and/or denial activities to management as needed. UM Nurse will work post discharge, prebill accounts efficiently and effectively daily to resolve accounts with missing authorization numbers, ALOS vs. Evaluates clinical documentation in patient records and escalates issues through the established chain of command. Tracks avoidable days accurately in the avoidable day module in EPIC. Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. 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 * 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. * Advocates for patient and negotiates and refers for services that maybe required outside of patients 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. Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor for resolution. Works post-discharge/prebill accounts efficiently and effectively daily, to resolve accounts with no auth numbers, ALOS vs. Evaluates clinical documentation in patient records and escalates issues through the established chain of command. Serves as a preceptor and/or or mentor for other professional and/or students Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (mcg Indicia) * Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor for resolution. Initiates assessment for necessity andappropriateness of health services by the application of established screening criteria (mcg Indicia). * Ensure timely identification and referral for alternative level of care. * Responsible for timely and accurate certification/authorization of hospital admissions and hospital days. * Ensures authorizations are documented in EPIC on time. * 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. * Advocates for patient and negotiates and refers for services that maybe required outside of patients 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. Works post discharge, prebill accounts efficiently and effectively daily to resolve accounts with missing authorization numbers, ALOS vs. Evaluates clinical documentation in patient records and escalates issues through the established chain of command. Serves as a preceptor and/or or mentor for other professionals and/or students. Complies with all WellStar Health System policies, standards of work, and code of conduct.

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

RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact Knowledge of Case Management process. 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. Strong computer skills required. Connect with the most integrated health system in Georgia, and start a future that gives you more.