RN Utilization Management - FT/PRN - North Fulton

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

Job summary

Wellstar Health System is seeking an experienced Utilization Management Nurse (UM) Coordinator to perform medical necessity reviews around the clock, applying MCG criteria and documenting in EPIC. You will coordinate with payers and care teams to ensure appropriate care levels and timely authorizations.

Responsibilities include concurrent reviews, discharge planning, and resolving authorization discrepancies while supporting safe transitions of care and patient advocacy.

Qualifications

• Associates Nursing or Diploma, RN license; Bachelor’s preferred.
• Current RN license (state-specific or Compact).
• Minimum 3 years of clinical experience.
• Knowledge of case management processes and screening criteria (e.g., MCG).

Responsibilities

• Initiate assessment for necessity and appropriateness of health services using established screening criteria (e.g. MCG).
• Obtain timely authorization of hospital admissions and days; document in EPIC.
• Monitor and evaluate care plans and concurrent reviews based on set standards.
• Communicate with payors to resolve discrepancies and ensure proper authorizations.
• Post-discharge/prebill account resolution and documentation of reviews.

Skills

Case Management

Communication skills

Organizational skills

Physician relationships

Clinical review criteria

Critical thinking

Computer skills

Education

Associate's Degree in Nursing

Diploma in Nursing

Bachelor's Degree in Nursing

Tools

EPIC

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 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 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 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.

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 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.

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

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.