RN Utilization Management Specialist

Wellstar Health System, Inc.; United States; On-site; USD 75,000 - 110,000; Full time

Job summary

Wellstar Health System, Inc. is seeking an Utilization Management Nurse to perform medical necessity reviews up to 12 hours daily across the week, using MCG criteria and Indicia tools, coordinating safe transitions of care for defined patient populations.

You will work with physicians and the care team, conduct chart reviews, obtain timely authorizations, and ensure accurate EPIC documentation to support billing and post-discharge processes.

Qualifications

• Associates degree or Diploma in Nursing required.
• BSN preferred.
• RN license (State-specific) required.
• Minimum 3 years of clinical experience in a medical/surgical or utilization/case management setting.
• Experience with Medicare/Medicaid regulations is a plus.

Responsibilities

• Assesses necessity and appropriateness of health services using established screening criteria (e.g. MCG).
• Secures timely certification/authorization for hospital admissions and days.
• Obtains payer authorizations and documents in EPIC.
• Monitors plan of care and conducts concurrent reviews.
• Collaborates with physicians, advisors, and care team to optimize transitions of care.
• Supports post-discharge/pre-bill account resolution.

Skills

Case Management

Communication

Organization

Relationships

Screening criteria

Critical thinking

Computer skills

Education

Associates Nursing or Diploma

Nursing-Bachelors Preferred

Job description

Wellstar Health System, Inc. is seeking an Utilization Management Nurse to perform medical necessity reviews up to 12 hours daily across the week, using MCG criteria and Indicia tools, coordinating safe transitions of care for defined patient populations.

You will work with physicians and the care team, conduct chart reviews, obtain timely authorizations, and ensure accurate EPIC documentation to support billing and post-discharge processes.