Onsite Utilization Management Nurse

Wellstar Health System; Roswell (GA); On-site; USD 85,000 - 110,000; Full time

Job summary

Wellstar Health System in Georgia is seeking an on-site Hospital Utilization Management (UM) Nurse to be the main link between the clinical floor and administrative compliance. The role emphasizes real-time, face-to-face collaboration with physicians, patients, and multidisciplinary teams to optimize hospital resources.

Responsibilities include medical necessity reviews, physician liaison duties, and bedside rounds, with a focus on reducing denials and ensuring Medicare/Medicaid compliance.

Qualifications

• Associates degree, Diploma or Bachelor in Nursing; BSN preferred.
• Active RN license (state-specific or multi-state compact).
• Minimum 3 years of nursing experience.
• Knowledge of case management processes and payer regulations.

Responsibilities

• Meet in person with providers to discuss cases where documentation does not support medical necessity.
• Serve as on-site liaison between attending providers and physician advisor for complex medical determinations.
• Attend bedside rounds and department huddles to advise on medical necessity and care progression.
• Perform on-site concurrent reviews using criteria like InterQual/MCG.
• Identify and escalate avoidable hospital days to minimize costs.
• Ensure compliant documentation for payers and accurate post-discharge coding.
• Support continuous performance improvement initiatives and adherence to policies.

Skills

Case Management

Verbal & Written Communication

Organizational Skills

Team Collaboration

Screening Criteria

Critical Thinking

Computer Skills

Education

Associates or Diploma in Nursing

Tools

EHR

Job description

Wellstar Health System in Georgia is seeking an on-site Hospital Utilization Management (UM) Nurse to be the main link between the clinical floor and administrative compliance. The role emphasizes real-time, face-to-face collaboration with physicians, patients, and multidisciplinary teams to optimize hospital resources.

Responsibilities include medical necessity reviews, physician liaison duties, and bedside rounds, with a focus on reducing denials and ensuring Medicare/Medicaid compliance.