Registered Nurse (RN) - Utilization Management - PRN - North Fulton

3410 Wellstar North Fulton Hospital, Inc.; United States; On-site; USD 85,000 - 110,000; Full time

Job summary

Wellstar North Fulton Hospital is seeking a Utilization Management Nurse to perform medical necessity reviews using MCG criteria and coordinate with physicians to guide patients to appropriate care settings. This role supports timely authorizations and seamless transitions across care teams.

The position requires an Associate Degree in Nursing or Diploma, RN license, and 3+ years of clinical experience, with day shifts in the United States.

Qualifications

• Strong clinical knowledge with nursing practice experience.
• Ability to review medical records and apply eligibility criteria.
• Collaborates with physicians and care teams to coordinate patient care.

Responsibilities

• Initiates and completes medical necessity reviews using established criteria (e.g. MCG).
• Ensures timely certification/authorization of hospital admissions and days.
• Documents reviews accurately in EPIC and communicates with payors.
• Monitors post-discharge/prebill accounts and resolves discrepancies.
• Escalates denial issues to management and participates in performance improvement.

Skills

Clinical knowledge

Communication

Attention to detail

Education

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

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: The Utilization Management (UM) Nurse is responsible for conducting medical necessity reviews up to 12 hours per day, on any of the 7 days per week, utilizing Indicia for Case Management, and performs clinical reviews through document review, discussion with physicians and collaboration with the care team on the coordination of safe transitions of care for a defined patient population. The UM Nurse will perform utilization review every day by looking at all new admissions, all observation cases and concurrent reviews. They will be assigned to specific units/and or payer/and or patient class. All clinical reviews will be done by utilizing mcg Indicia, Indicia for Admission Documentation (IAD), and Indicia for Effective Focus (IEF) criteria in conjunction with medical records documentation and communication with physicians and physician's advisors. The UM nurse gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to complete the determination/recommendation for the most appropriate level of care status and shares pertinent clinical information to the payers. Along the continuum of care, the UM Nurse communicates with providers and other parties to facilitate care/treatment. The UM Nurse identifies opportunities to ensure effectiveness of healthcare services in the most appropriate setting always, as well as timely discharge to the most appropriate level of post discharge care. The UM Nurse obtains timely authorization of all ALOS days from payers and ensures accurate and complete documentation in the appropriate place in EPIC to enable timely billing. UM RN monitors post-discharge, prebill accounts that do not have an authorization on file, ALOS versus days authorized variances, and/or other account discrepancies identified that will result in the account being denied by the payor that require clinical expertise. The UM Nurse communicates with third party payors to resolve discrepancies prior to billing, accurately and concisely documents all communications regarding and actions taken on the account in accordance with policies and procedures, and escalates medical review request and/or denial activities to management as needed. The UM Nurse works post-discharge/prebill accounts efficiently and effectively daily, to resolve accounts with no authorization numbers, ALOS vs. authorized days, or other discrepancies. The UM Nurse evaluates clinical documentation in patient records and escalates issues through the established chain of command. The UM Nurse tracks avoidable days accurately in the avoidable day module in EPIC per department Standard Work and performs accurate and timely documentation of all review activities.

Core Responsibilities and Essential Functions:

Utilization Management

• Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG).
• Ensures timely identification of need and referral for alternative level of care.
• Responsible for timely and accurate certification/authorization of hospital admissions and hospital days.
• Provides required information to payors in a timely fashion and obtains appropriate authorization for all days. Ensures authorizations are documented in EPIC in a timely manner.
• Monitors and evaluates patient/clients ongoing plan of care and conducts timely concurrent reviews based on set standards, utilizing screening criteria to determine level of care 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.
• Advocates for patient and negotiates and refers for services that maybe required outside of patients health care coverage.
• 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. 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.

Documentation and Post Discharge

• Completes chart notes accurately and on time per Departmental protocol.
• Ensures all records are up-to-date.
• Ensures timely and accurate documentation of clinical reviews and insurance updates as required by payor including authorized days and denied days with reason for denial.
• Works post-discharge/prebill accounts efficiently and effectively daily, to resolve accounts with no auth numbers, ALOS vs. authorized days or other discrepancies.
• Evaluates clinical documentation in patient records and escalates issues through the established chain of command.

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 ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor Additional License(s) and Certification(s):

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

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.