RN Utilization Management - FT/DAY - WMCG

Wellstar Health System; Crestdale (SC); On-site; USD 85,000 - 105,000; Full time

Job summary

Wellstar Health System is seeking an on-site Hospital Utilization Management (UM) Nurse to serve as the primary link between the clinical floor and administrative compliance, with in-person interaction with doctors, patients, and interdisciplinary teams to optimize hospital resources.

Day shift in a hospital setting, focusing on physician consultation, medical necessity reviews with InterQual/MCG criteria, and collaboration to manage ER throughput and patient length of stay.

Responsibilities

• Utilization Management monitors and evaluates patient care and conducts concurrent reviews based on set standards.
• Monitors and evaluates the appropriateness of managed care denials and works with attending physician and advisors to overturn denials.
• 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 bed huddles to provide input on medical necessity and criteria-led care progression.
• Provide consultation on cases admitted through the Emergency Department to assess new admissions and recommended level of care.
• Identify and support continuous performance improvement initiatives based on Medicare/Medicaid regulations.

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. 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 elevate 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