On‑Site Utilization Management Nurse — Real-Time Care & Throughput

Wellstar Health System; Crestdale (SC); On-site; USD 85,000 - 105,000; Full time

Job summary

Wellstar Health System is seeking an on-site Hospital Utilization Management (UM) Nurse to serve as the primary link between the clinical floor and administrative compliance, with in-person interaction with doctors, patients, and interdisciplinary teams to optimize hospital resources.

Day shift in a hospital setting, focusing on physician consultation, medical necessity reviews with InterQual/MCG criteria, and collaboration to manage ER throughput and patient length of stay.

Responsibilities

• Utilization Management monitors and evaluates patient care and conducts concurrent reviews based on set standards.
• Monitors and evaluates the appropriateness of managed care denials and works with attending physician and advisors to overturn denials.
• 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 bed huddles to provide input on medical necessity and criteria-led care progression.
• Provide consultation on cases admitted through the Emergency Department to assess new admissions and recommended level of care.
• Identify and support continuous performance improvement initiatives based on Medicare/Medicaid regulations.

Job description

Wellstar Health System is seeking an on-site Hospital Utilization Management (UM) Nurse to serve as the primary link between the clinical floor and administrative compliance, with in-person interaction with doctors, patients, and interdisciplinary teams to optimize hospital resources.

Day shift in a hospital setting, focusing on physician consultation, medical necessity reviews with InterQual/MCG criteria, and collaboration to manage ER throughput and patient length of stay.