Utilization Management RN: Care Coordination & Reviews

3410 Wellstar North Fulton Hospital, Inc.; United States; On-site; USD 85,000 - 110,000; Full time

Job summary

Wellstar North Fulton Hospital is seeking a Utilization Management Nurse to perform medical necessity reviews using MCG criteria and coordinate with physicians to guide patients to appropriate care settings. This role supports timely authorizations and seamless transitions across care teams.

The position requires an Associate Degree in Nursing or Diploma, RN license, and 3+ years of clinical experience, with day shifts in the United States.

Qualifications

• Strong clinical knowledge with nursing practice experience.
• Ability to review medical records and apply eligibility criteria.
• Collaborates with physicians and care teams to coordinate patient care.

Responsibilities

• Initiates and completes medical necessity reviews using established criteria (e.g. MCG).
• Ensures timely certification/authorization of hospital admissions and days.
• Documents reviews accurately in EPIC and communicates with payors.
• Monitors post-discharge/prebill accounts and resolves discrepancies.
• Escalates denial issues to management and participates in performance improvement.

Skills

Clinical knowledge

Communication

Attention to detail

Education

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

Job description

Wellstar North Fulton Hospital is seeking a Utilization Management Nurse to perform medical necessity reviews using MCG criteria and coordinate with physicians to guide patients to appropriate care settings. This role supports timely authorizations and seamless transitions across care teams.

The position requires an Associate Degree in Nursing or Diploma, RN license, and 3+ years of clinical experience, with day shifts in the United States.