Registered Nurse (RN) - Utilization Management – FT/Day - Augusta

Wellstar Medical Group, LLC; Augusta (GA); In loco; USD 90.000 - 110.000; Tempo pieno

Descrizione del lavoro

Wellstar Medical Group, LLC in Augusta, Georgia, is seeking an on-site Utilization Management Nurse (RN) to bridge clinical floors with administrative compliance. You will review admissions and concurrent care to ensure proper patient class and facilitate efficient hospital throughput.

In this role, you will liaise with attendings, care teams, and the Physician Advisor, participate in daily rounds, and support accurate documentation and payer communications.

Competenze

• RN licensed and eligible in Georgia.
• Minimum 3 years clinical experience in hospital settings.
• Familiarity with InterQual/MCG criteria is preferred.

Mansioni

• Conduct on-site medical record reviews to validate medical necessity and appropriate level of care.
• Collaborate with physicians and care teams to discuss cases requiring documentation support.
• Provide real-time input during bedside rounds and department huddles to optimize throughput.
• Deliver legally required notices and support payer communications to prevent denials.
• Ensure compliance with Medicare/Medicaid regulations and organizational policies.

Conoscenze

RN

Clinical assessment

InterQual/MCG

Hospital throughput

Formazione

Associate Degree in Nursing

Strumenti

EPIC EHR

Descrizione del lavoro

How would you like to work in a place where your contributions and ideas are valued? 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
Day (United States of America)

Job Summary:

As an on-site Hospital Utilization Management (UM) Nurse, you are the primary link between the clinical floor and administrative compliance. Unlike remote roles, this position relies heavily on real-time, face-to-face interaction with doctors, patients, and interdisciplinary teams to optimize hospital resources.
The on-site UM Nurse is a Registered Nurse (RN) responsible for performing admission and concurrent medical record reviews to ensure patients are in the correct Patient Class (e.g., Inpatient vs. Outpatient with Observation). By being physically present, one is able to directly influence the hospital's throughput, length of stay, and reimbursement accuracy.
Key On-Site Responsibilities
Physician and Clinical Collaboration
o 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.
o Medical Provider Liaison: Function as the primary on-site link between the attending/admitting provider and the Physician Advisor for complex medical necessity determinations.
Real-Time Patient Class Decision Support
o Interdisciplinary Huddles: Attend daily bedside rounds or departmental "bed huddles" to provide immediate input on medical necessity and criteria-led care progression.
o ER Throughput Management: 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.
Administrative & Financial Compliance
o Medical Necessity Reviews: Use criteria like InterQual or MCG to perform on-site concurrent reviews of active patient care.
o Issuing Official Notices: Deliver and explain legally required documents in person, such as condition-code 44 or Medicare observation notices (MOON).
o Denial Prevention: Proactively identify "avoidable days"hospital days that do not meet clinical criteriaand escalates them to the management team to minimize financial loss.

Core Responsibilities and Essential Functions:

Utilization Management
Monitors and evaluates patient/clients ongoing plan of care and conducts timely concurrent reviews based on set standards, utilizing screening criteria to monitor care progression 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
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 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.
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. InterQual, MCG)
• Assesses insurance and coverage requirements for all payers and ensure adherence to those requirements at all time.
• Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor for resolution.
• Ensures timely identification of need and referral for alternative level of care.

Documentation and Post Discharge

• Completes chart notes accurately and on time per Departmental protocol.
• Ensures all records are up-to-date.
• Use criteria like InterQual or MCG to perform on-site concurrent reviews of active patient care.
• Deliver and explain legally required documents in person, such as condition-code 44 or Medicare observation notices (MOON).
• Proactively identify "avoidable days"hospital days that do not meet clinical criteriaand escalates them to the management team to minimize financial loss.

Professional Development and Initiative

• Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
• Serves as a preceptor and/or 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.

Required Minimum Education:

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

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.
- RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact
- BLS - Basic Life Support or BLS-I - Basic Life Support - Instructor or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I-P - Basic Life Support Instructor-Provisional (180 Days) within 90 Days

Additional License(s) and Certification(s):

BLS within 90 Days Required

Required Minimum Experience:

Minimum 3 years Strong clinical knowledge with clinical practice/experience Required

Required Minimum Skills:

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.