UM Nurse RN-Onsite

Wellstar Health System; Georgia; On-site; USD 75,000 - 95,000; Full time

Job summary

Wellstar Health System in Georgia is seeking an on-site Hospital Utilization Management (UM) Nurse. You will perform admission and concurrent medical record reviews to ensure patients are in the correct class (Inpatient vs Outpatient with Observation) and influence throughput, LOS, and reimbursement accuracy.

The role requires direct collaboration with physicians, attendance at bedside rounds or bed huddles, and on-site communication to resolve cases.

Qualifications

• Active RN license required (single state) or RN-Compact multi-state license
• Current Basic Life Support (BLS) certification required
• Familiar with InterQual criteria for medical necessity reviews
• Familiar with MCG guidelines for concurrent reviews
• Knowledge of Medicare/Medicaid regulations and payer requirements

Responsibilities

• Meet in person with attending/admitting providers to discuss cases where documentation does not support medical necessity or the current level of care.
• Serve as the on-site link between attending providers and physician advisor for complex medical determinations.
• Attend bedside rounds or bed huddles to provide input on medical necessity and care progression.
• Perform on-site concurrent reviews of active patient care using established criteria (e.g., InterQual, MCG).
• Deliver and explain required notices such as MOON or condition-code 44 in person.
• Identify and communicate opportunities to avoid unnecessary hospital days and support denial prevention and throughput improvements.

Skills

RN

BLS

InterQual

MCG

Medicare regulations

Education

Associates Nursing or Diploma (Nurse) Nursing or Bachelors Nursing-Preferred

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.The on-site UM Nurse is a Registered Nurse (RN) responsible for performing admission and concurrent medical record reviews to ensure patients are in the correct Patient Class (e.g., Inpatient vs. Outpatient with Observation). 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

• 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.
• 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

• Interdisciplinary Huddles: Attend daily bedside rounds or departmental "bed huddles" to provide immediate input on medical necessity and criteria-led care progression.
• 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

• Medical Necessity Reviews: Use criteria like InterQual or MCG to perform on-site concurrent reviews of active patient care.
• Issuing Official Notices: Deliver and explain legally required documents in person, such as condition-code 44 or Medicare observation notices (MOON).
• Denial Prevention: Proactively identify "avoidable days"hospital days that do not meet clinical criteriaand escape them to the management team to minimize financial loss.

Core Responsibilities and Essential Functions

• Monitors and evaluates patient/clients ongoing plan of care and conducts timely initial and 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 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.
• Proactively identify "avoidable days"hospital days that do not meet clinical criteriaand escape them to the management team to minimize financial loss.

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
• 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 B