Utilization Management Nurse – Care Coordination & Authorization

3110 Kennestone Hospital, Inc.; United States; On-site; USD 75,000 - 105,000; Full time

Job summary

Wellstar Health System is seeking a Utilization Management Nurse to conduct medical necessity reviews and coordinate safe transitions of care across units and payers. The role uses established criteria (MCG) and guidance in medical record reviews and collaborates with the care team to ensure appropriate levels of care.

You will document in EPIC, obtain authorizations, and support discharge planning while communicating with physicians and payors to optimize patient throughput and minimize delays.

Qualifications

• Requires RN license and related nursing degree.
• Minimum 3 years of clinical case management experience.
• Strong communication and documentation skills.

Responsibilities

• Initiate assessment for necessity and appropriateness of health services using established screening criteria.
• Obtain authorizations and document accurately in EPIC in a timely manner.
• Conduct concurrent reviews and coordinate discharge planning with care teams.
• Collaborate with physicians/physician advisors to overturn denials when appropriate.
• Monitor compliance with payer regulations and maintain thorough records.
• Participate in performance improvement initiatives.

Skills

Case Management

Communication

Organizational Skills

Physician Collaboration

Screening Criteria Knowledge

Clinical Documentation

Computer Skills

Education

Associates Nursing

Nursing Diploma

Bachelor's in Nursing (Preferred)

Tools

EPIC

IAD/IEF Criteria

Job description

Wellstar Health System is seeking a Utilization Management Nurse to conduct medical necessity reviews and coordinate safe transitions of care across units and payers. The role uses established criteria (MCG) and guidance in medical record reviews and collaborates with the care team to ensure appropriate levels of care.

You will document in EPIC, obtain authorizations, and support discharge planning while communicating with physicians and payors to optimize patient throughput and minimize delays.