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

WellStar Health System; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

Wellstar Health System seeks an on-site Hospital Utilization Management (UM) Nurse. The RN acts as the primary link between the clinical floor and administrative compliance, performing admission and concurrent chart reviews to ensure correct patient class and care level.

You will influence throughput, length of stay, and reimbursement accuracy by working directly with doctors and care teams. You will collaborate with physicians, attend bedside rounds, and provide real-time input on medical

Qualifications

• RN license in good standing and state nursing credentials.
• Minimum 3 years of clinical hospital experience.
• Associates or Diploma in Nursing; Bachelor's preferred.
• Current BLS certification.

Responsibilities

• Meet in person with physicians to discuss cases where documentation does not support medical necessity or current level of care.
• Collaborate with attending/admitting providers, physician advisors, and care teams on complex determinations.
• Attend bedside rounds to provide input on medical necessity and care progression.
• Perform on-site medical necessity reviews and ensure payer requirements are met.
• Deliver required notices in person, e.g. MOON or condition-code 44 when needed.

Skills

Clinical knowledge

Interdisciplinary collaboration

Documentation accuracy

Education

Associate Degree in Nursing

Diploma in Nursing

Bachelor of Science in Nursing

RN license (state)

BLS certification

Job description

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 escape them to the management team to minimize financial loss.

Core Responsibilities and Essential Functions

• 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 escape 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 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. Nationally ranked and locally recognized for our high-quality care and inclusive culture, Wellstar is one of Georgia’s largest and most integrated healthcare systems. Every day, 24,000+ of us work together to provide personalized care for patients at every age and stage of life – and our team members are the foundation of that care.

Mission, Vision & Values

Mission, Vision & Values At a time when the healthcare industry is changing rapidly, Wellstar remains committed to exceeding patients’ and team members’ expectations, while transforming healthcare delivery.

OUR MISSION

To enhance the health and well-being of every person we serve.

OUR VISION

Deliver world-class healthcare to every person, every time.

OUR VALUES

We serve with compassion We pursue excellence We honor every voice

Culture of Excellence

Wellstar consistently receives attention and accolades from national organizations that set the standards for world-class care. Our system-wide practice of safety principles, assessing and addressing errors and seeking feedback from our patients and customers continually earns recognition for advances in safety and quality. Featured on the FORTUNE “100 Best Companies to Work For” list and Seramount 100 Best Companies list, we not only provide top-notch care for our patients, but also foster the culture of Wellstar as a Great Place to Work.