RN Central UM Onsite

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

Job summary

Wellstar Health System in Georgia seeks an on-site Utilization Management Nurse (RN) to bridge clinical care and administrative compliance. This role performs admission and concurrent reviews to ensure correct patient class (Inpatient/Outpatient) and supports real-time throughput decisions.

You will collaborate with physicians, attend bedside rounds, and utilize criteria like InterQual/MCG to determine medical necessity, impacting stay length and reimbursement accuracy through direct, on-site

Qualifications

• Registered Nurse with current license.
• Experience with medical necessity determinations.
• On-site hospital utilization management knowledge.

Responsibilities

• Physician consultations in person with attending/admitting providers to discuss cases where documentation does not support medical necessity or current level of care.
• Medical provider liaison: primary on-site link between attending/admitting provider and physician advisor for complex determinations.
• Attend daily bedside rounds or bedside huddles to provide input on medical necessity and care progression.
• Provide on-site reviews of active patient care using criteria like InterQual or MCG for medical necessity.
• Deliver and explain legally required documents in person, such as notifications related to level of care and observation status.

Skills

RN

On-site collaboration

Medicare/Medicaid compliance

Tools

InterQual/MCG

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
  • 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.
  • 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
  • Interdisciplinary Huddles: Attend daily bedside rounds or departmental "bed huddles" to provide immediate input on medical necessity and criteria-led care progression.
  • 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
  • Medical Necessity Reviews: Use criteria like InterQual or MCG to perform on-site concurrent reviews of active patient care.
  • Issuing Official Notices: Deliver and explain legally required documents in person, such as condition-code 44 or Medicare observation notices (MOON).
  • 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

• Utilization Management
  • Monitors and evaluates patient/clients ongoing plan of care and conducts timely initial and 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