RN Utilization Management - FT/PRN - North Fulton

Wellstar Health System; Roswell (GA); On-site; USD 70,000 - 95,000; Full time

Job summary

Wellstar Health System in Georgia is seeking a skilled professional to join our utilization management team in Roswell. You will help assess necessity and appropriateness of health services, secure timely authorizations, monitor ongoing plans of care, and coordinate posts discharge documentation to ensure compliance with payer rules.

The role emphasizes collaboration with physicians and care teams, ongoing professional development, and mentoring of others to improve patient throughput and

Qualifications

• Strong clinical knowledge with clinical practice/experience.
• Medium to high verbal and written communication skills.
• High organizational skills and ability to build strong physician relationships.

Responsibilities

• Initiates assessment for necessity and appropriateness of health services using screening criteria.
• Assesses insurance and coverage requirements for all payers and ensures adherence.
• Identifies issues and collaborates with physicians for admission resolution.
• Completes chart notes accurately and on time per protocol.
• Ensures timely documentation of clinical reviews and insurance updates.
• Supports continuous performance improvement and compliance with payer regulations.

Skills

Clinical knowledge

Communication skills

Organizational skills

Physician relationships

Screening criteria

Critical thinking

Computer skills

Job description

Work Shift

Day (United States of America)

Job Summary

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.

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.

Performs other duties as assigned Complies with all WellStar Health System policies, standards of work, and code of conduct.

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

Assessment

• Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (mcg Indicia)
• 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.

Utilization Management

• Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (mcg Indicia).
• Ensure timely identification 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 on time and obtains appropriate authorization for all days. Ensures authorizations are documented in EPIC on time.
• 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.

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 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.

Professional Development and Initiative

• Completes all initial and ongoing professional competency assessments, required mandatory education, and population specific education.
• Serves as a preceptor and/or or mentor for other professionals and/or students.

Performs other duties as assigned Complies with all WellStar Health System policies, standards of work, and code of conduct.

Additional License(s) And Certification(s)

Required Minimum Experience

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

Required Minimum Skills

Knowledge of Case Management process. Medium Excellent verbal and written communication skills. High Strong organizational skills. High Ability to build strong and trusting relationships with physicians and the multidisciplinary team. High Knowledgeable with utilizing screening criteria in review of clinical data and identifying variance. Medium Ability to critically think and analyze information, effect change, and effectively impact timely throughput. High Strong computer skills required. High

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