RN Utilization Review Case Manager – Care Coordination

St. Mary's Health Care System; Athens (GA); On-site; USD 65,000 - 90,000; Full time

Job summary

St. Mary's Health Care System in Georgia is seeking a Utilization Review (UR) Coordinator to collaborate with physicians, nurses, and payers to ensure appropriate levels of care across the hospitalization continuum.

You will conduct clinical reviews using MCG and InterQual criteria to support patient status determinations and resource utilization. You will serve as a liaison with external payers, manage authorizations, and document findings in the EPIC EMR while adhering to HIPAA and regulatory

Qualifications

• GA RN license required; BLS required.
• Graduate of an accredited school of nursing; BSN recommended.
• Three to five years related experience and clinically relevant knowledge.

Responsibilities

• Collaborate with multidisciplinary team to ensure appropriate level of care.
• Conduct reviews using MCG and INTERQUAL criteria.
• Serve as liaison with external payers for medical necessity.
• Document criteria reviews and approvals in EPIC EMR.
• Manage payer authorizations and notifications to support reimbursement and regulatory compliance.
• Support utilization management reporting and performance improvement initiatives.

Skills

Clinical analysis

MCG INTERQUAL

Organizational skills

Communication

Attention to detail

Computer skills

Education

RN licensure

BSN recommended

Tools

EPIC

Microsoft Word

Microsoft Teams

Microsoft Outlook

Microsoft Excel

Job description

St. Mary's Health Care System in Georgia is seeking a Utilization Review (UR) Coordinator to collaborate with physicians, nurses, and payers to ensure appropriate levels of care across the hospitalization continuum.

You will conduct clinical reviews using MCG and InterQual criteria to support patient status determinations and resource utilization. You will serve as a liaison with external payers, manage authorizations, and document findings in the EPIC EMR while adhering to HIPAA and regulatory