Utilization Management Nurse – PRN Days (Acute Care)

Wellstar Health Systems, Inc.; Richmond (VA); On-site; USD 90,000 - 120,000; Full time

Job summary

Wellstar Health System is seeking an experienced Utilization Management Nurse Coordinator to perform medical necessity reviews and coordinate care across the patient continuum. Working at Cobb Hospital, you will engage with providers, payors, and care teams to ensure appropriate levels of care and timely authorizations.

The role requires 3+ years of clinical experience, RN licensure, and proficiency with EPIC and MCG criteria.

Qualifications

• Associates Degree or Nursing Diploma required; Bachelor's preferred.
• RN license in the relevant state (compact licensure preferred).
• Minimum 3 years of clinical experience in utilization management or related field.
• Knowledge of Case Management processes and payer regulations.
• Strong verbal and written communication; highly organized.

Responsibilities

• Conduct medical necessity reviews 24/7 using MCG-based criteria.
• Coordinate certification/authorization of hospital admissions and days.
• Provide timely information to payors and obtain appropriate authorizations.
• Communicate with care teams and providers to facilitate appropriate levels of care.
• Document reviews and actions in EPIC; track post-discharge authorizations.
• Escalate issues per established chain of command.

Skills

Clinical knowledge

Communication skills

Organization

Payer/CM knowledge

Education

Associates/Nursing Diploma

Bachelors in Nursing (Preferred)

Tools

EPIC

MCG Indicia/ criteria

Job description

Wellstar Health System is seeking an experienced Utilization Management Nurse Coordinator to perform medical necessity reviews and coordinate care across the patient continuum. Working at Cobb Hospital, you will engage with providers, payors, and care teams to ensure appropriate levels of care and timely authorizations.

The role requires 3+ years of clinical experience, RN licensure, and proficiency with EPIC and MCG criteria.