Registered Nurse (RN) - Utilization Review -Acute Care PRN Days

Wellstar Health System; Greenfield (SC); Sur place; USD 55 000 - 69 000; Temps partiel

Résumé du poste

Wellstar Cobb Hospital is seeking a Utilization Management Nurse (UM) Coordinator to conduct medical necessity reviews 24/7, using mcg Indicia, and share findings with payers and care teams to ensure safe transitions of care.

In this PRN Day role, you will review new admissions, observations, and concurrent cases, obtain authorizations, document in EPIC, and coordinate with providers to optimize patient outcomes and reduce denials.

Qualifications

• Minimum 3 years strong clinical knowledge with clinical practice/experience.
• PRN status requires four shifts in a four-week schedule.

Responsabilités

• Conduct medical necessity reviews 24/7 using established criteria (MCG).
• Obtain timely authorizations for hospital admissions and days and document in EPIC.
• Collaborate with physicians, payers and care teams to coordinate safe transitions of care.
• Escalate denials and participate in compliance with payer regulations.

Connaissances

Clinical knowledge

Communication skills

EPIC EMR

MCG Indicia

Outils

EPIC EMR

MCG Indicia

Description du poste

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)

This role is PRN Days - at Cobb Hospital

Learn more about Cobb Hospital:

locations/hospital/cobb-medical-center

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

PRN Requirements:

four (4) shifts in a four-week schedule period

Work one (1) major and one (1) minor holiday per year, or as otherwise assigned by departmental rotation.

Job Summary:

The Utilization Management Nurse (UM) Coordinator is responsible for conducting medical necessity reviews 24 hours per day, 7 days per week. Utilizing mcg Indicia, clinical reviews are performed and clinical information shared with payers and authorization status shared with the care team on the coordination of safe transitions of care for a defined patient population.

The Utilization Management 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 payer(s)/and or units/and or patient class. All clinical reviews will be performed, utilizing mcg Indicia when specified, in conjunction with medical records documentation communication with physicians and physician's advisors.

The UM nurse will gather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to complete the determination/recommendation for the most appropriate level of care status and provide supporting clinical information to the payers. Along the continuum of care, communicates with providers and other parties to facilitate care/treatment.
Utilization Management Nurse will obtain timely authorization of all ALOS days from payers and ensure this is documented in the appropriate place in EPIC to enable timely billing. Will monitor 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 will communicate with third party payors to resolve discrepancies prior to billing. Accurately and concisely documents all communications and action taken on the account in accordance with policies and procedures. Escalate medical review request and/or denial activities to management as needed

UM Nurse will work post discharge, prebill accounts efficiently and effectively daily to resolve accounts with missing authorization numbers, ALOS vs. authorized days or other discrepancies. Evaluates clinical documentation in patient records and escalates issues through the established chain of command. Tracks avoidable days accurately in the avoidable day module in EPIC. Perform 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