On-Site UM Nurse: Real-Time Care Optimization

3110 Kennestone Hospital, Inc.; United States; On-site; USD 90,000 - 115,000; Full time

Job summary

Wellstar Health System is seeking an on-site Utilization Management Nurse (RN) to bridge the clinical floor and administrative compliance. This role emphasizes in-person admission and concurrent record reviews to assure proper patient class and care level, directly impacting throughput and reimbursement.

The position requires strong clinical knowledge, case-management expertise, excellent communication, and teamwork with physicians.

Qualifications

• Knowledge of Case Management process.
• High 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.

Responsibilities

• 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.
• Medical Provider Liaison: 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.
• Issuing Official Notices: Deliver and explain legally required documents in person, such as condition-code 44 or Medicare observation notices (MOON).
• Denial Prevention: Proactively identify “avoidable days” hospital days that do not meet clinical criteria and elevate them to the management team to minimize financial loss.
• 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.

Education

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

Job description

Wellstar Health System is seeking an on-site Utilization Management Nurse (RN) to bridge the clinical floor and administrative compliance. This role emphasizes in-person admission and concurrent record reviews to assure proper patient class and care level, directly impacting throughput and reimbursement.

The position requires strong clinical knowledge, case-management expertise, excellent communication, and teamwork with physicians.